August 11th 2022
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 centred online learning 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 60 yr old male patient, construction worker by occupation and a resident of suryapet came with chief complaints of pedal edema since 1 month.
History of presenting illness:
Patient was apparently asymptomatic 2 years back.
Then he went to local hospital and diagnosed with diabetes since 2 years.He is using medications for diabetes.
Then after an year he went to local hospital and diagnosed with hypertension.
Since one year he developed pain in both the lower limbs and using NSAIDS since then.
Now 1month back ,he developed pedal oedema and also loin pain.
He also had decreased urine output,breathlessness and burning micturition.
Since 2 weeks he had decreased appetite,low grade fever and generalized weakness.
No history of facial puffiness.
Past history:
He is known case of diabetes since 2 years and hypertension since 1 year.
Personal history:
Loss of appetite
Bowel: regular
Micturition: normal
No allergies
Had habit of alcohol but stopped since 5 months.
Family history:
Not significant
General examination:
Patient was conscious, coherent, cooperative and well built and nourished
No pallor,clubbing, cyanosis,icterus, generalized lymphadenopathy
Bilateral pedal oedema present of pitting type.
Vitals:
Temp:afebrile
Pulse:82bpm
Respiratory rate:14cpm
Blood pressure:120/70 mm Hg
Systemic examination:
Cardiovascular system:S1, S2+ and no murmurs are heard.
Respiratory system: normal vesicular breath sounds are heard
Central nervous system: no functional deficits
Abdomen:
no tenderness,no palpable mass
Investigations:
Provisional diagnosis:
CRF on medical management
Treatment:
Salt and fluid restriction
Tab.Nicardia 20 mg per oral/BD
Tab.Lasix 40 mg per oral/BD
Cap Bio D3 weekly per oral
Tab .Nodosis 500 mg per oral/ BD
Syp.Aristozyme 15 ml per oral/TID
