43yr old male with SOB , Anasarca

Ankitha 

Rollno : 78


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 centered online learning portfolio 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 . 


Cheif Complaints :


C/O SOB since 1 week

C/O Pedal edema since 1 week

C/O Abdominal distension since 1 week


HOPI :

Patient was apparently, asymptomatic 1 year back he started having pedal edema of grade 1 which was reduced on taking medication but gradually progressed to grade 2 and ultimately anasarca. Then he also had complaints of SOB, facial puffiness , distension of abdomen and was taken to private hospital and diagnosed as renal failure , there was persistent increase in creatinine so he was started on hemodialysis  - 18 sessions of dialysis was done. 

Patient came to our hospital 3 months back with same complaints 

From then he is undergoing dialysis in our hospital.

Presently ,

C/O SOB since 1 week - Grade 3 , Orthopnea present , PND present

C/O Swelling of whole body since 1 week gradually progressive (relieved with dialysis and aggravated during nights .)

C/O fever since 1 week , on and off , low grade , intermittent and no chills and rigor.


Past H/O :

K/c/o HTN since 2months on 

Tab.Nicardia 20mg , Tab. MetXL 25mg

Patient was on hemodialysis since 3months

No H/O DM , Cad , Cva , Epilepsy


PERSONAL HISTORY :


DIET : MIXED

APPETITE : Normal 

SLEEP : Inadequate (2-3hrs) due to SOB and pain post iv cannulation

BOWEL AND BLADDER HABITS : REGULAR

NO ALLERGIES


GENERAL EXAMINATION-

PT. IS C/C/C

B/L PEDAL EDEMA OF FEET G-II

NO PALLOR , ICTERUS,CYANOSIS,CLUBBING, LYMPHEDENOPATHY 

















Vitals :

TEMP - AFEBRILE

PR-80

BP-140/80MMHG

RR-16CPM


SYSTEMIC EXAMINATION :

CVS-S1S2+,NO MURMURS

RS - BAE+,NVBS , Crepts present

P/A-SOFT,NON TENDER

On percussion - dull note

CNS-NFND


INVESTIGATIONS :













PROVISIONAL DIAGNOSIS : 


CKD ON  MHD secondary to NSAID Abuse


TREATMENT :


  1. Tab. NICARDIA 20 mg PO/TID
  2. Tab. MET -XL 25mg PO/OD
  3. Tab. NODOSIS 500mg PO/BD
  4. INJ- LASIX 40mg IV/BD
  5. Tab SHELCAL PO/OD
  6. SALT RESTRICTION < 2gm/day
  7. Fluid Restriction <1lt /day.
  8. Intermittent : CPAP


Comments

Post a Comment

Popular posts from this blog

A69 YR OLD MALE WITH BILATERAL HYDROURETERO NEPHROSIS AND AKI ON CKD

Image
  THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT . Name : Ankitha reddy Roll no : 67 CASE :  A 69 year old male who is farmer by occupation came to the opd with cheif complaints of : B/L pedal edema present since 15 days Burning micturation since 15days Increased frequency of micturition (10-15times per day ) and urgency  Nocturia 5-6 times  Itching all over the body since 7 days HISTORY OF PRESENTING ILLNESS:  Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and buring micturition . There is increased frequency of urination i.e; 10 to 15times per day and nocturia...
Read more

32 yr old male with fever and generalized weakness

Image
MEDICAL ONLINE BLENDED BIMONTHLY ASSIGNMENT(MAY-2021)  32 yr old male with fever and generalized weakness    This is an 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 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 valuable inputs on the comment box NAME : Ankitha Reddy ROLL NO : 67 A 32yr old male who is a farmer by occupation was brought to casualty with  CHEIF COMPLAINTS :  FEVER since 1 week. HEADACHE since  5 days GENERALISED WEAKNESS AND JOINT PAINS HISTORY OF PRESENT ILLNESS:  Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( o...
Read more

Internship Assessment

Name : Ankitha Roll no : 78 2017 Batch Period of Posting : 12/02/23 to 13/04/23 This blog is all about my learning experiences  in 2 months of my internship while i was posted in general medicine department. First i had Psychiatry posting for 15 days  During Psychiatry  postings : 1. I got to see numerous cases in the opd which includes schizophrenia , depression, alcohol dependence disorder , drug addiction , postpartum blues , anxiety , panic attacks . 2. I learnt to take history of such diverse cases and understood the importance of patient confiding in us and how it impacts our diagnosis and treatment. 3. I learnt to manage and monitored patients in delirium  4. I visited de-addiction centre and learned about the activities done there and treatment given for those patients. 5. I learnt to do mental status examination  Then i was posted in UNIT-6 in medicine department for 1month  OP AND UNIT duty experience: We had op days every Saturday and saw approxi...
Read more