This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
A 32 year old male patient came to the opd with chief complaints of decreased urine output ,bilateral pedal edema, and shortness of breath.
HOPI: patient was apparently asymptomatic 1year back then he developed loss of consciousness for which he went to the local hospital, there he had noticed b/l pedal edema of pitting type. Patient also has pain in rt. Leg 6 months back for which he had operation.
- patient also had low urine output, burning micturition since 1 yr back.
- patient also has SOB of grade 2.
Daily routine ;
he wakes up at 6am and takes his breakfast at 7:30am.which includes idli and chapathi. After breakfast he watches T.V . he takes his lunch at 11:00am. Which includes rice and dal. Then he sleeps for 2 hours. Then at 7:00pm he takes his dinner. Which includes rice and dal. And sleeps at 9:00pm.
PAST HISTORY:
K/c/o: hypertension since 5years.
And not a known case of DM,TB, EPILEPSY.
PERSONAL HISTORY:
diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions: none
EXAMINATION:
Patient was conscious, coherent, cooperative,well oriented to time ,place and person.
Pallor is seen
No-Icterus,cyanosis, clubbing, lymphadenopathy.
Temp- Afebrile (98.5f)
Bp- 140/90 mm hg
PR- 99 BPM
RR- cpm
Spo2-91%
Systemic examination:
CVS: s1 and s2 are heard .no cardiac murmurs.
RS: dyspnea is present,no wheezing,trachea is central .
Normal vesicular breath sounds are heard.
ABDOMEN :
Shape of abdomen is scaphoid. Abdomen is soft.
No palpable mass , no tenderness, no hernial orifices.
CNS : NAD
Provisional diagnosis : ckd on mhd
Treatment:
Salt restriction <3.4gm/day
Fluid restriction <1.4lit/day
TAB. lasix 40mg
TAB. Shelcal
TAB. Nicardia 10mg
TAB. Drofer
TAB. Nodosis 500mg
Inj. Erythropoietin 4000IU
CBP:
ECG
