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. CHIEF COMPLAINTS
The patient of 65 years came to hospital 4 days back with complaints of shortness of breath since 1 year, bilateral pedal edema since 1week and diarrhoea and fever since 4 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year ago when he developed shortness of breath, which is exacerbated by physical activity and also present at rest. Developed bilateral pedal edema since 1 week, pitting type. Also had episode of diarrhoea 4days ago associated with fever.
History of past illness
Had undergone laparotomy for appendicitis 30 years back.
Known case of Chronic kidney disease since 2 years.Known case of hypertension since 2 years.
On medication: T.Prazosin 10mg ,T.Arkamine 0.1mg, T.Clinidipine 10mg
TREATMENT HISTORY
- Diabetes - No
- Hypertention - Yes
- CAD - No
- Asthama - No
- Tuberculosis - No
- Antibiotics - No
- Hormones - No
- Chemo / Radiation - No
- Blood Transfusion - No / Yes,
- Surgeries - Yes, Details:Abdominal Surgery Lapotomy
- Other
PERSONAL HISTORY
Occupation daily wage worker
Married
Diet:mixed
Appetite:normal
Sleep:normal
No known allergies
FAMILY HISTORY
Diabetes - No
Hypertension -yes
Heart disease - No
Stroke - No
Concern - No
Tuberculosis-no
Asthma - No
General examination
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is seen
SYSTEMATIC EXAMINATION:
B. CARDIO VASCULAR SYSTEM
1. Thrills: No
2. Cardiac Sounds : Heart sounds
3. Cardiac murmurs: No
C. RESPIRATORY SYSTEM
1. Dyspnoea - yes
2. Wheeze - No
3. Position of Trachea - Central
4. Breath Sounds - Vesicular
5. Adventilious Sounds - No
D. ABDOMEN
1. Shape of abdomen - Scaphoid
2. Tenderness - No
3. Palpable mass - No
4. Hernial Orifices: Normal
5. Free Fluid: No
6. Bruits: No
7. Liver - Not palpable
8. Spleen - Not palpable
9. Bowel sounds -Yes
Central nervous system
1.Level of conscious conscious and cohertness: normal
2.Speech: normal
3.Sign of meningeal irrigation
Neck stiffness: no
Kerning sign: no
4.Cerebral signs
Finger nose test: in coordination
Knee heel test: in coordination
Investigation
Provisional diagnosis:Chronic kidney disease
Treatment: MHD
