This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient 
clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.
New Admission 
ICU Bed no.1
30 Year old Male Came with C/o Fever, SOB and Pain abdomen since 1 day
 Patient was dumb and deaf from birth.But He was not any other Health Problems But 10 years back  He was having fever and was also diagnosed with AKI due to analgesic abuse and underwent dialysis for 4 times then was having no complaints for few years then he was having cough with sputum and was diagnosed with TB 1 year back and was under ATT for 6 months.
Then 10 days back he was having Fever associated with decreased urine output from 5 days and Abdominal pian with decreased Appetite and complaints of Vomiting from 1 day and SOB since 1 day. Taken to a Local hospital and was referred to our hospital as His Creatinine was high(5.9).
Vitals At Presentation(18-11-22)
Bp 60/40
PR 112
RR 40cpm
SpO2 72
PH - 7.076
Noradrenaline Given at 4ml/Hr 


18/11/22

19/11/22


21/11/22
22/11/22



Pt on Ventilation
Vitals (19-8-22)
Bp 80/40
PR 50
SpO2 96
Ventilation settings
ACMV mode
RR 18 breaths min
RR total 18
FiO2 70% PEEP 6cm H2o
VT 400ml 
Psupport 10cm H2o
Diagnosis
Septic Shock with MODS 
K/c/o Pulmonary Kochs 1 Year Back
H/o Dialysis 10 Years Back 

Treatment
Inj Meropenem 500mg IV Bd
IV fluids NS 50ml/hr
RT feeds 100ml water 2nd hrly
100ml milk 4th hrly
Tab Doxycycline100mg RT BD
Inj Vasopressin 2.4ml/hr infusion
Inj Dobutamine 3.6ml/hr infusion
Inj Norad 2 ampules 46ml Ns
Tab Dolo 650mg RT BD
Inj Neomol IV sos
Inj Pantop40mg iv OD
Neb with Salbutamol 2 respules 4th hrly
Inj vit k 10mg in 100ml NS IV over 30 min

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