This is an 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
A 59 yr old male patient came to OPD with cheif complaints of B/L pedal edema and shortness of breath since 3 months
HOPI: patient was apparently asymptomatic 3 months ago then he developed B/L pedal edema which is pitting type which is aggravated towards end of the day and subsides in morning and shortness of breath(Grade:2) and He also has Periorbital puffiness for which he went to private hospital in suryapet and used medication prescribed by them but he was not satisfied then he went to NIMS in Hyderabad 15 days ago for which they diagnosed him with chronic renal failure and done 2 rounds of heamodialysis,the patient came to us for follow up,he is undergoing heamodialysis in our hospital.
PAST HISTORY:
He is a known case of hypertension and Type 2 Diabetes mellitus since 12 years.
He is not a K/C/O TB,asthma, epilepsy,thyroid disorders.
PERSONAL HISTORY:
Diet-Mixed
Appetite-Normal
B and B movements- Regular
Sleep- Disturbed
No addictions
DAILY ROUTINE: Patient is shop vendor by occupation, he wakes up by 7 to 7:30am in mrng and does his personal activities and has breakfast at 9am and goes to his shop and comes to home for lunch at 1 Pm and after having lunch sleeps upto 3.30 pm and wakes up and goes to shop and returns to home for dinner around 8 pm and then he watches Tv and do conversations with neighbours upto 10 pm then he goes to sleep.
TREATMENT HISTORY: pt is on antihypertensives and Oral hyperglycemic agents.
FAMILY AND ALLERGIC HISTORY: No relevant history
GENERAL EXAMINATION:
Patient was conscious, cooperative,well oriented to time,place , person.Moderately built and nourished.
PALLOR WAS PRESENT
NO CYANOSIS
NO ICTERUS
NO CLUBBING
NO GENERALISED LYMPHADENOPATHY
NO EDEMA
VITALS::
TEMP AFEBRILE
PR 74 bpm
RR 12cpm
BP 120/80mmHg
SYSTEMIC EXAMINATION:
*Cardiovascular system :
S1,S2 heard
No murmurs heard
*Respiratory system:
Chest shape - normal
Trachea- central
Normal vesicular breath sounds are heard
*P/A examination:
It is Soft and Non tender
No organomegaly.
*Central nervous system:
no focal neurological deficit
PROVISIONAL DIAGNOSIS:
Chronic Renal Failure
INVESTIGATIONS:
Liver function test: serum alkaline phosphatase elevated-202 IU/L (Normal:56-119)
Urine examination:Serum albumin-2+
Renal function tests:
Urea:117mg/dl(12-42)
Creatinine:5.6mg/dl(0.9-1.3)
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