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.
Unit 1
AMC bed 5
DOA:29/5/23
45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of
Abdominal distension since 5 days
B/L swelling of lower limbs since 15 days
HOPI :he was apparently asymptomatic 15 days back then he developed swelling of both lower limbs (extending up to 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 ,SOB and vomitings
No h/o chest pain ,orthopnea ,PND,palpitations
No h/o deceased urine output,burning micturition ,fever
Past history:
K/c/o DM since 5 years on tab.metformin Po/BD
Not a k/c/o HTN,TB,BA,epilepsy,CAD,CVD
Personal history:
Diet :mixed
Appetite:decreased
Bowel and bladder:regular
Sleep :adequate
Addictions:chronic alocoholic since 10years
No known allergies
Family history;insignificant
General examination :
Pt is c,c,c .well oriented to time ,place, person
He is moderately built and moderately nourished
PALLOR-present
CLUBBING-absent
LYMPHADENOPATHY-absent
EDEMA-present
VITALS;
TEMP:afebrile
PR:118bpm
RR:22cpm
BP:130/80 mm Hg
Spo2:95%@RA
Local examination;
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 hepatomegaly
Percussion:
No fluid thrill and shifting dullness
Auscultation:
Bowel sounds are heard
Systemic examination;
RS: BAE+,NVBS
CVS: S1,S2 HEARD
CNS; INTACT
Investigations:
Hemogram:
CXR:
Treatment:
Inj.pan 40mg IV/OD
Inj.thiamine 200mg in 100ml Ns /IV /TID
Inj.zofer 4mg/IV/TID
Inj.lasix 20mg IV/OD
No comments:
Post a Comment