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.
I have been given this cas
Case:
A 70 year old man who is a carpenter by occupation resident of pannagiri presented to casualty with chief complaints of shortness of breath since 1 week, Anuria since 4 days, Pain abdomen since 1 day.
History of presenting illness:
Patient was apparently asymptomatic 6 years(2016) back then he developed shortness of breath and was taken to the hospital and dialysis was done for about 4 times.
He was taking NSAIDS for his body pains since 20 years he stopped using them after dialysis was done.1 week back then he suddenly development shortness of breath of intially grade 4 for which he was taken to the some local hospital but the shortness of breath did not subside he was then taken to an another hospital where he also developed anuria since 4 days and bilateral pedal edema which is pitting type till the level below the knees, abdominal distension, puffiness of face since 2 days during his hospital stay.
There is no history of hesitancy, urgency, burning micturation.
Patient then developed pain abdomen which is diffuse, non radiating, dull aching type with no associating and reliving factors.
No history of fever, nausea and vomiting.
History of past illness:
10 days back he suffered paralysis of upper and lower limbs along with deviation of mouth to right,slurred speech and was resolved in 2 days when treated by a local doctor.
6 years back one days he didn't wake up from his sleep and was seen by a local practioner and found to have his systolic blood pressure over 180mmhg and was given medication for 3 days and again went to check up and was normotensive since then.
No history of blood transfusion.
Not a known case of diabetes mellitus,asthma,epilepsy,TB,CAD.
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bladder movements-decreased urine output since 4days
Bowel movements-regular
Addictions:He smokes bedi(5to6 per day) and alcoholic since he was young and stopped 6 years back.
No drug allergies.
General examination
Patient is conscious, coherent and cooperative. moderately built and nourished.
Pallor is present.
Icterus-absent
Clubbing-absent
Cyanosis-absent
Generalised lymphadenopathy-absent
Pedal edema-absent
Vitals
Temperature - Afebrile
Pulse rate 90bpm
Blood pressure 130/80mmhg
Respiratory rate
Systemic examination
CVS- S1 and S2 heart sounds heard, no murmurs.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
PER ABDOMINEN:
INSPECTION
No distention
No scars
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
No local rise of temperature
Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.
PERCUSSION
No hepatomegaly
Fluid thrill and shifting dullness absent.
AUSCULTATION
Bowel sounds present.
No bruit or venous hum.
CNS EXAMINATION:
Couldn't be assessed as he is intubated.
Provisional diagnosis
Chronic kidney disease.
Investigations :
Chest x ray:
USG abdomen:
Ecg on 9-8-2022
Ecg on 10-8-2022
Treatment
On 9/8/22
Inj.lasix 80mg IV/stat
Inj.lasix 100mg 5mg/hr
Tab.Prazosin 5mg BD/PO
Tab.Met XL 50mg BD/PO
Tab.Nicardia 20mg BD/PO
Tab.Nodosis 500mg BD/PO
Tab.Rosuastatin 10mg + Tab.Clopidogrel 75mg OD/PO
On 10/8/22
RT feeds 200ml milk + 100ml water
Tab.Nodosis 500mg RT TID
Tab.Nicardia 10mg RT BD (check BP before giving)
Inj.Lasix 40mg IV TID(if BP greater than 110/80)
Tab.Ecospirin 75/20mg RT OD
Inj.Pantop 40mg IV/OD
Tab.Orofer-XT RT/OD
Inj.Erythropoietin 4000IU sc twice weekly
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