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.
A Shishira Reddy
1701006005
ICU Bed 5, 44yr old man
Chief complaints:
A 44year man came with chief complaints of
-B/L pitting type of pedal edema since 10 days , ----decreased urine output since 5 days
- pain abdomen since 4 days
-vomiting 1 day back
History of presenting illness:
He was asymptomatic 1 one and 1/2 yrs back , then he had swelling in face and lower limbs and visited doctor , and was on medication . He stopped medication after 10 days.
After few days he had difficulty in breathing (SOB grade 2) and decreased urine output
He was admitted to hospital and was on dialysis for 2 days .
Since then he was on dialysis twice every week.
Patient was apparently asymptomatic 10 days back and gradually developed B/L pitting type of pedal edema & decreased urine output.
Pain in the epigastric region since 4 days , pricking type of pain, non radiating, aggravated after food and relieved on its own after some time .
History of vomiting of 6-7 EPISODES which was non bilious , consisted of food particles and was relieved on medication .
Past history:
K/C/O HTN since 4 years but didn't use any medication
N/K/C /O DM ,TB , EPILEPSY, ASTHMA.
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel n bladder: irregular , decreased urine output progressed to anuria.
Addiction: alcohol consumption qty: 180ml 3-4 times a week at night , since 15years
And stopped since 1and 1/2 year.
No History of smoking
Family history: no significant history
General examination
Pt is concious and coherent and cooperative well oriented to time place and person,
On examination
Pallor present( mild) , no icterus/ clubbing/ cyanosis / lymphadenopathy /edema (apparently)
Temp: 98°F
BP : 140/100mmHg
RR: 28/min
PR : 80/min
SPO2: 99% @ RA
CVS: S1 S2 +
RS : BAE +
CNS : NAD
P/A : tenderness and pain in the epigastric region
Provisional diagnosis: ?acute gastritis
CKD on MHD, HTN +
Investigations
21/08/22 RFT
21/08/22 LFT
21/08/22 ABG
20/08/22 ECG
20/08/22 HEMOGRAM
20/08/22 ABG
19/08/22 SERUM ELECTROLYTES
19/08/22 TROPONIN
Plan of treatment:
1.Fluid and salt restriction
2. INJ. ZOFER 4 mg IV/ TID
3. INJ. TRAMADOL 1 AMP in 100 ml NS IV / SOS
4. TAB. NICARDIA 10 mg PO/TID
5. TAB. ARKAMIN 0.1mg PO/BD
6. TAB. MET- XL 25 mg PO/OD
7. TAB. SHELCAL 500mg PO/ OD
8. Cap. BIO-D3 PO/OD/WEEKLY ONCE
9. INJ. ERYTHROPOIETIN 4000 IU S/L WEEKLY TWICE
10. BP MONITORING 2nd hrly
11. GRBS 2nd hrly.
