48/M with sob and renal failure
This is online E log book 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 available global online community of experts with an aim 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 comment box is 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.
CHIEF COMPLAINTS
Bilateral Pedal Edema since 1 month
Shortness of breath since 1 day
Vomitings since 1 day
History of presenting illness
Patient was apparently asymptomatic One month back then he developed Bilateral Pedal Edema which was insidious in onset ,gradually progressive, pitting type extending from ankle.
Patient also complained of shortness of breath, insidious in onset, gradually progressive, aggrevated by work and relieved on rest.
Patient had history of vomitings since 1 day with Food as contents,non projectile, non bilious.
Patient also had decreased urine output.
HISTORY OF PAST ILLNESS
No similar complaints in the past
Patient had history of tuberculosis and was on ATT therapy for 3 months
Known case of HYPERTENSION since 5 years and is on medication
Not a known case of Epilepsy and coronary artery disease
Patient had previous history of RTA and underwent surgery of right leg.
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Appetite is reduced
Diet is mixed
Bowel and Bladder movements Regular
Sleep Adequate
No Addictions
Drinks alcohol occasionally
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
Pallor-present
Icterus-mild Icterus is present
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present(pitting type)
VITALS:
Temperature-98.4
Pulse rate-84beats per minute
Respiratory rate-16 breaths per minute
Blood pressure-140/90mm hg
SpO2-98 at room air
SYSTEMIC EXAMINATION
Cardiovascular system-S1 and S2 heard ,no murmurs heard
Respiratory system:
No dyspnoea
Breath sounds-vesicular breath sounds are normal
Central nervous system:
Patient was conscious,coherent and cooperative.
Speech was normal
No slurred speech
No Meningeal irritation signs
-No abnormality detected.
Reflexes are normal
Abdomen is soft and non tender
Pleural tap was done on 16-11-22
INVESTIGATIONS
HAEMOGRAM
RENAL function test
Liver function test
Random blood sugar
Anti HCV ANTIBODIES RAPID
PROVISIONAL DIAGNOSIS
CHRONIC RENAL FAILURE
TREATMENT:
T.LASIX 40 mg PO OD
T.NICARDIA 1O mg PO OD
T.NODOSIS 500mg PO OD
T.OROFER PO OD
T.SHELAL PO OD
INJ.HAI S/C acc to GRBS
Syp.ASCORIL PO TID 15ml
Vitals monitoring 4th hourly
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