This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian 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 the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble 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.
AMC BED 1 :
A 45 year old female ,resident of Nalgonda came to OPD on 19/4/23 with c/o
SOB since 1 day
Generalised swelling of the body since 1 month
Generalised body pains since 3 months
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months ago ,then she developed swelling of both lower limbs extending from ankle to knee (pitting type) followed by swelling of face ,upper limbs and abdomen,which is insidious in onset gradually progressive ,associated with pain.
C/O SOB (grade 2) ,insidious in onset ,gradually progressive ,no aggravating and relieving factors
Not associated with cough,chest pain ,palpitations and fever ,orthopnea and PND.
C/O generalised body pains with tingling sensation of all four limbs (on and off)
No H/O Fever ,cough ,cold,pain abdomen ,vomitings ,loose stools ,burning micturition.
PAST HISTORY:
k/c/o HTN since 3 years (on regular medication Tab.CINOD 10mg PO/OD)
k/c/o DM since 3 years (on regular medication Glimi -m2 PO/OD
Not a k/c/o thyroid ,epilepsy,BA,TB,CAD.
Took iron injections 3 months ago I/v/o low Hb
PERSONAL HISTORY:
Diet :mixed
Appetite :normal
Bowel and bladder :regular
Sleep :adequate
No known allergies
No addictions
Family history: not significant
General examination:
Patient is conscious,coherent,cooperative
Well oriented to time ,place and person
Temp:98.6F
PR:84bpm
RR:22cpm
Bp:180/100mmofhg
Spo2:97%
GRBS: 102mg/dl
Pallor +
No icterus ,clubbing ,cyanosis ,lymphadenopathy,
Oedema +
Systemic examination:
RS: BAE +,NVBS
CVS:s1,s2+
P/A:soft ,non tender
Provisional diagnosis:
Renal AKI on CKD ( secondary to diabetic nephropathy)
Anemia under evaluation
Investigatons:
CXR:(19/4/23)
USG abdomen :(19/4/23)
#E/o free fluid noted in B/L pleural spaces
ECG:(19/4/23):
Treatment:
Fluid restriction <1.5 L/day
Salt restriction <2gm /day
Tab.Aldactone 50mg/po/OD
Tab.cinod 10mg po/Bd
Inj.HAI s/c TID
W/H OHA
Inj.EPO 4000 U s/c weekly once
2 egg whites /day
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