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 comments on 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.
Presenting complaints
65M presented with the chief c/o fever since 5 days.
Decreased appetite since 5 days.
Vomitings 4 episodes since today morning
Involuntary movements since today morning
Hopi-
Patient was apparently asymptomatic 5 days back then he had fever with chills, intermittent with evening rise in temperature resolved after taking medication after 2 days.
Till yesterday he was normal, then after hemodialysis yesterday he had generalised weakness and involuntary movements of both upper limbs and lower limbs without loss of consciousness, without any involuntary micturition/defecation. Since today morning he had c/o vomitings. 4 episodes (non bilious/non projectile, non blood stained) food particles as content
Past history
K/c/o DM since 30 years
K/c/o HTN since 30 years
H/o CAD - PTCA in sept 2022, feb 2023
K/c/o HCREF
k/c/o ckd since 6 months
Personal history
Occupation - driver
Decreased appetite since 1 month
Stopped alcohol 10 years ago
Occasional smoking stopped 10 years ago
General examination
Patient is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema
Systemic examination
Cvs: s1 s2 + , no murmurs
Rs: BAE + ; nvbs
P/a: distended, no organomegaly
Cns: hmf+, nfnd
Investigations:
Prothrombin time: 17 sec
INR: 1.25
APTT: 34 SEC
BGT: B POSITIVE
HCV: NON REACTIVE
HBSAG: NEGATIVE
HIV: NON REACTIVE
RBS: 128mg/dl
Serum iron: 73ug/dl
Provisional diagnosis: CKD on MHD with HTN, DM, CAD
Treatment plan
Inj lasix 40mg iv/bd
Tab nicardia 20mg po/tid
Tab shelcal po/od
Tab nodosis 500 mg po/bd
Tab clopidogrel 75 mg po/od
Inj HAI s/c tid acc to grbs
Tab met xl 25 mg po/od
Comments
Post a Comment