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 70 year old man toddy tree climber, came to casualty with the chief complaints of
1) B/L pedal edema since 20
2) facial puffiness since 20days
History of presenting illness:
Patient was apparently asymptomatic 3yrs back when he complained of generalized weakness on & off for which their sons convinced him to stop climbing trees.
He to used wake up at 6 am , used to do his routine activity followed by breakfast and tea by 9am. He used to sit in the corridor and play with the kids , talk to neighbour. He used to have his lunch at 11am , sleeps for 1-2 hrs. He used to have dinner by 7pm .
20 days back when pt woke up from bed , he suddenly noticed pedal edema, pitting type and facial puffiness.
No c/o chest pain , palpitations, SOB.
Burning micturition since yesterday.
Nausea and 1 episode of vomiting which was non bilious and a/w food particles
Cough intermittent since 7 days
Past history:
H/o bleeding PR since 1 year
N/k/c/o DM , HTN, EPILEPSY, ASTHMA, TB.
PERSONAL HISTORY:
Sleep adequate,
Appetite normal
Diet mixed
Bowel - irregular,
Bladder regular
Addiction: regular alcoholic , 90ml whisky
Smoking -20 beedis per day
Family history
Not significant
General examination
Patient is concious
. Pallor - present
No Icterus, clubbing, cyanosis, lymphadenopathy
Edema of feet grade 3
Temp- 98.3°F
BP:140/70mmHg
PR:76bpm
RR:21cpm
CVS: S1 S2 +
RS:BAE +
CNS: NAD
P/A: Soft , non tender
Provisional diagnosis:
Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy
Investigations:
13/09/22
LFT
Serum creatinine
14/09/22
ecg
15/09/22
Hemogram
Treatment:
1)INJ .IRON SUCROSE 200 mg in 100 ml NS IV / OD
2)INJ LASIX 40 mg IV/ OD
3)INJ ZOFER 4 mg IV / TID
4)SYP CREMAFFIN 30 ml PO/ OD / HS
5) TWO EGG WHITES PER DAY
15-09-22
O/E
Pt is c/ c/c
Temp- Afebrile to touch
BP- 110/70mm hg
PR- 82 bpm
SpO2- 98% with RA
GRBS- 112mg/dl
CVS- s1, s2 +
CNS- NAD
LUNGS- BAE+, NVBS
Rx
1)INJ .IRON SUCROSE 200 mg in 100 ml NS IV / OD
2)INJ LASIX 40 mg IV/ OD
3)INJ ZOFER 4 mg IV / sos
4)SYP CREMAFFIN 30 ml PO/ OD / HS
5) TWO EGG WHITES PER DAY
6)MONITOR VITALS AND INFORM SOS only
16-09-22
S: dizziness, tinnitus
O:
Pt is c/c/c
Temp. 99°F
BP: 110/70
PR:84
SPO2 98%
CVS- S1, S2 +
RS-BAE+
CNS-NAD
GRBS- 92mg/dl
A: Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy
P:
1) INJ. IRON SUCROSE 200ml NS/IV/OD
2) INJ. LASIX 40mg/IV/OD
3)INJ. ZOFER 4mg/ IV/SOS
4) SYP. CREMAFFIN 30ml/PO/OD/HS
5)TWO EGG WHITES /DAY
6) MONITOR VITALS &INFORM SOS
7) TAB. VERTIN 16mg PO/BD
17-09-22
Hemogram
18-09-22
Hemogram
AMC bed 4,
70 year old male.
S: bleeding PR
O:
Pt is c/c/c
Temp. 98°F
BP: 110/70mmHg
PR:78bpm
SPO2 98%
CVS- S1, S2 +
RS-BAE+, NVBS
CNS-NAD
GRBS- 108mg/dl
A: Severe Anemia under evaluation with bleeding PR 2° ? Fissure? Malignancy
P:
1) INJ. IRON SUCROSE 200mg in 100 ml NS/IV/OD
2)INJ. ZOFER 4mg/ IV/SOS
3) SYP. CREMAFFIN 30ml/PO/OD/HS
4) TAB. PROMETHAZINE 10mg/PO/TID
5) OINTMENT ANOBLISS
5)TWO EGG WHITES /DAY
6) MONITOR VITALS &INFORM SOS
