CASE 1: A 67yr male came with difficulty of micturition, breathlessness and distended abdomen

Hi, I am . S Shivraj 5th semester medical student. 

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 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.   

  

        A 67 yr old male patients who is the resident of changanpath came to  OPD with the chief complaint of difficulty in micturition since 1 month with decrease in urine output since 15 days, breathleesness  since 10 days , bloating of abdomen since 1 week 

History of present illness 

     The patient is aprently asymptomatic till 1 month ago then he developed  difficulty in micturition along with reduction of urine output and frequency of urination for that patients is admitted private hospital  

       Constipation since 25 days ago.Then patient developed fever 20 days ago associated with chills and rigor ,the fever is High grade, intermedient their is no aggravating factor but reduced by medication.   

           The patients complain bloating of abdomen and shortness of breathing since 1  week ago .

History of past illness

      The patient have DM since 13 years Their is no history of HTN,TB, asthma.their is history of blood transfusion in 2020 once.

      The patient have significant surgical history of amputation of right foot toe due to infection.

Personal history

      The patient is vegetarian, taking adequate sleep, doen not smoke or drink alcohol.

Family history

   No significant family history

 Physics examination :

General examination

      The patient is concious, coherent and cooperative. Moderately build and no pallor, no ictures and no lymphadenopathy . No clubbing of fingers.

       The patient have edema , which is pitting type and grade1 .

Vitals 

1) Temperature : 101 F 

2) Pulse Rate :  88 beat per min 

3) Respiratory Rate : 20 cpm

4) Blood pressure : 130/80 mmHg 

5) Spo2:   97 %

(1). Systemic examination :

1) CVS examination : 

    Cardiac sound : s1 and s2 present

     Aortic regurgitation : Present

    

2) Respiratory system examination

       Weeze: absent 

       Position of trachea: Central

       Breathing Sounds : vesicular

3) Examination of abdomen : 

    1) shape of abdomen : distended

    2) tenderness :  yes

    3)  Palpable mass : no

    4) palpable liver : no 

    5) palpable spleen : no