This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.
Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case 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.
A 57 year old male resident of miryalaguda came to OPD with
CHIEF COMPLAINTS :
- Since 5 days :
Generalized body weakness
Pain over upper abdomen
Bilateral pedal edema
Burning sensation of both soles
- SOB at rest since 3 days
HISTORY OF PRESENT ILLNESS :
- Patient was apparently asymptomatic 2 years ago then he developed pain in the foot for which he went to a local hospital and was on some pain killers ( unknown) for about an year later he felt relieved and discontinued the drug.
- After few days again he felt pain and went to a hospital during investigations he was diagnosed as kidney failure. He used some medication for it
- Then, 5 days ago he developed generalised body pain which is aggravated on exertion and relieved on medication.
- He also experienced burning pain over epigastric region which is also aggravated on exertion and relieved on medication.
- Fever was also present with chills and rigors.
- Bilateral pedal edema was developed which aggravated on walking and relieved on rest.
- Burning sensation of both soles which is present through out the day and SOB at rest.
- Nausea and giddiness since yesterday.
PAST HISTORY :
- K/c/o Chronic kidney disease
( Use of NSAID'S for 1 year due to pain near 1st metatarsal joint and foot )
Diabetes - No
Hypertension - No
TB - No
Asthma - No
Epilepsy - No
CVD - No
Chemo/Radiation Exposure - No
Surgical history - Nil
FAMILY HISTORY : Nil significant
PERSONEL HISTORY :
Diet - Mixed
Appetite - lost since 10-15 days
Bowel and bladder - Regular movements
Allergies - No
Addictions - Chewing tobacco
- 90 ml of whiskey occasionally (Once in a month) but stopped 4 months ago
GENERAL EXAMINATION :
Temperature - 102 °F
Pulse - 96 beats/min
BP - 180/90 mmHg
RR - 34 cycles/min
Pallor - Present
Icterus - No
Clubbing - No
Cyanosis - No
Lymphadenopathy - No
Pedal edema - Present
Arcus Senilis - Present
Locomotor brachii - Present
SYSTEMIC EXAMINATION :
CVS :
No thrills
No murmurs
S1 and S2 heard
RESPIRATORY SYSTEM :
Position of trachea - Central
Dyspnoea , Wheeze - Present
Breath Sounds - vesicular
ABDOMEN :
Shape - Scaphoid
No Tenderness
No palpable mass
Umbilicus inverted
Bowel sounds heard
CNS : Normal
- Patient is Consious, Coherent, Well oriented to time place and surroundings.
INVESTIGATIONS :
HIV 1/2 Rapid - Non reactive
HBsAG Rapid - Non Reactive
Anti HCV Antibodies Rapid - Negative
Blood group - B Negative
31/8/22 -
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE with intermittent fever and chest pain.
TREATMENT :
30-08-2022 -
Rx :
1. Fluid and salt restrictions
2. Inj lasix 40mg IV / BD
3. Tab.Pantop 40mg PO/OD
4. Tab. Dolo 650mg PO/TID
5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F
6. Tab. Nodosis 500mg/PO/TID
7. Tab. Shelcal 500mg PO/OD
8. Cap bio D3 PO/weekly once
9. Tab. Ultracet half PO/BD for 3 days
10. Syp. Aristozyme 15 ml PO/TID (20 min before food)
31-08-2022 -
On examination :
Patient is C/C/C
BP : 120/60 mm of Hg
PR : 82bpm
CVS : S1, S2 present
RR : 22 cpm
RS : BAE +
P/A soft
CNS : NAD
Temperature : 101°F
GRBS : 97 mg/dl
Rx :
1. Fluid and salt restrictions
2. Inj lasix 40mg IV / BD
3. Tab.Pantop 40mg PO/OD
4. Tab. Dolo 650mg PO/TID
5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F
6. Tab. Nodosis 500mg/PO/TID
7. Tab. Shelcal 500mg PO/OD
8. Cap bio D3 PO/weekly once
9. Tab. Ultracet half PO/BD for 3 days
10. Syp. Aristozyme 15 ml PO/TID (20 min before food)
01-09-2022 -
On examination :
Patient is C/C/C
BP : 110/60 mm of Hg
PR : 76bpm
CVS : S1, S2 present
RR : 24 cpm
RS : BAE +
P/A soft and non tender
CNS : NAD
Rx :
1. Fluid and salt restrictions
2. Inj lasix 40mg IV / BD
3. Tab.Pantop 40mg PO/OD
4. Tab. Dolo 650mg PO/TID
5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F
6. Tab. Nodosis 500mg/PO/TID
7. Tab. Shelcal 500mg PO/OD
8. Cap bio D3 PO/weekly once
9. Tab. Ultracet half PO/BD for 3 days
10. Syp. Aristozyme 15 ml PO/TID (20 min before food)
02-09-2022 -
Diagnosis : CHRONIC RENAL FAILURE with chest pain
On examination :
Patient is C/C/C
BP : 110/80 mm of Hg
PR : 76bpm
CVS : S1, S2 present
RR : 20 cpm
RS : BAE +
CNS : NAD
Rx :
1. Fluid and salt restrictions
2. Inj lasix 40mg IV / BD
3. Tab.Pantop 40mg PO/OD
4. Tab. Dolo 650mg PO/TID
5. Inj. Neomol 1g IV / SOS
6. Tab. Nodosis 500mg/PO/TID
7. Tab. Shelcal 500mg PO/OD
8. Cap bio D3 PO/weekly once
9. Tab. Ultracet half PO/BD for 3 days
Comments
Post a Comment