This is an a 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 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.
CASE:
A 60 year old male patient resident of Yadadri who is a farmer by occupation came with complaints of Abdominal distension since 4 months ,Burning micturition since 4 months, Upper and lower limbs swelling since 1month constipation since 7days.
History of presenting illness:
Patient was apparently asymptomatic 11 years back when he got some injury to his right knee followed by which he developed swelling ( hematoma? ) and went through operation.
4 and half year back he fell down had a injury to the lower back region following which he had weakness of all four limbs . For 2 months he took conservative management ( eating fish and eggs) regained power gradually and was able to walk initially and later was able do some of his daily chores . Since last two years he is not able to walk at all.
4 years back patient developed gradual decrease in the urine output and retention with abdominal discomfort and SOB . When he was diagnosed with ? (BPH) Obstructive Uropathy . He was put on foleys catheter- changing every 7-10 days since 2 years as he is completely bedridden due to paralysis of all the 4 limbs
4 months back bilateral lower limb swelling gradually increased and spread to upper limbs . Abdominal distension and puffiness of face.
7days back patient complained of abdominal discomfort associated with constipation and passing flatus . Burning micturition since 4 months.
Past history:
No history of similar complaints in the past.
No H/o diabetes, hypertension, thyroid abnormality , CAD , epilepsy, TB , asthma.
Surgical history:
Patient went through some surgery ( unknown) 11 years back following injury to right knee.
Family history:not significant.
Personal history:
Diet - Mixed
Appetite- normal
Sleep- adequate
B & B - Foleys catheter- changes once in 7-10 days since 2 years
Decreased urine output since 4 months
Constipation with passing flatus since 4 days
Addictions- smoking since when he was 20 years old ( 3/day )
Stopped smoking since 2 years
Occasional toddy drinker , stopped since 2 years
GENERAL EXAMINATION-
Patient in conscious, coherent and cooperative
Moderately built and nourished
Pallor- present
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphadenopathy- absent
Edema- present in B/L upper and lower limb
Vitals:
Temperature- a febrile
BP - 130/80 mm of Hg
PR - 84bpm
RR- 17cpm
SYSTEMIC EXAMINATION-
Cardiovascular system:
S1, S2 - heart sounds heard , no murmurs heard.
Respiratory system:
Inspection:
Shape of chest - normal
Chest movements : bilaterally symmetrica.m
Palpation:-
All inspiratory findings are confirmed
Trachea central in position.
AUSCULTATION:
BAE+, NVBS
Abdomen examination:
INSPECTION
Shape : distended
Scar : Absent
Umbilicus: everted
Movements : normal
PALPATION
Tenderness: absent
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard
CNS examination:
Higher mental functions : intact
Patient is conscious, coherent and cooperative and well oriented to time , place and person .
Cranial nerve examination: intact
Motor system:
Tone - Right left
Upper limb Hypotonic Hypotonic
Lower limb Hypotonic Hypotonic
Power - Right left
Upper limb- 2/5. 3/5
Lower limb- 2/5 2/5
Reflexes- Right left
Biceps- - +++
Triceps +++ +++
Supinator - +++
Knee - ++
ankle - ++
plantar dorsiflexion dorsiflexion
Sensory examination: normal
Gait : cannot be accessed
PROVISIONAL DIAGNOSIS-
Quadriparesis secondary to trauma (Lesion maybe above the level of C5 C6 level)
CKD
INVESTIGATIONS-
11-8-2022
12-8-2022
17-8-2022
Treatment:
Inj Lasix 40mg / iv / TID
Inj PAN 40 mg / iv / TID
Inj Optineuron lamp in 100ml /NS/ iv / OD
Tab Nodosis 500 mg /PO/ BD
Tab shelcal 500 mg /PO/ BD
Ecosporin 75/ 10 mg /PO/OD
Fluid and salt restriction
BP / PR / Temp monitoring
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