June 1st 2023
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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.
Date of admission - 29 May 2023
45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of
Abdominal distension since 4-5 days
Abdominal bloating since 4-5 days
B/L lower limb swelling since 4 days
Shortness of breath since 3 days
History of present illness :
He was apparently asymptomatic 12 days back then he developed fever which subsided after 3 days.
Then there was yellowish discoloration of eyes and history of passing dark coloured urine since 9 days.
Bilateral swelling of lower limbs (extending upto knee, pitting type) insidious in onset ,gradually progressive, no aggravating and relieving factors.
Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors associated with bloating and SOB.
Slurred speech since 2 days.
No h/o chest pain ,palpitations
No h/o deceased urine output,burning micturition.
Past history :
K/c/o DM since 4-5 years on medication Tab Metformin 500mg po BD
N/k/c/o HTN CVA CAD TB EPILEPSY.
Personal history:
Diet :mixed
Appetite: decreased
Bowel habits - reduced
Micturition - normal
Sleep: adequate
Addictions: chronic alcoholic since 20 years, 3-6 units per day, last date of alcohol consumption - 28/5/23, 2 units of beer.
Smoking - regular since 25 years, daily one pack (beedi or cigarette)
General examination:
Vitals:
Temp:101.5F
Bp:90/60mm hg
PR:96bpm
RR:20cpm
Systemic examination:
CVS:s1s2+,no murmur
RS:BAE+,no added sounds
P/A:
Inspection; Shape of abdomen; distended
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
Palpation:
No tenderness
No organomegaly
Auscultation:
Bowel sounds heard
CNS: NFD
Investigations :
Treatment:
Inj.pan 40mg IV/OD
Inj.thiamine 200mg in 100ml Ns /IV /TID
Inj.zofer 4mg/IV/TID
Inj.lasix 20mg IV/OD
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