This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
78years old male came to casuality with
Chief complaints:
Difficulty in breathing since one month aggrevated since yesterday
History of presenting illness :
Patient was apparently asymptomatic 4 yr back and then he developed right leg swelling (filariasis) not taken any medication .3yrs ago patient had history of trauma to left leg (rod and plate fixation) since one month patient complaints of breathlessness (grade 3) insidious in onset gradually progressive aggrevated on walking and no seasonal variation.
15days back patient had decreased urinary out put for which urethral stiture dialation was done 1 week back
H/o orthopnea since 3 days
H/o weight loss from 2 week
H/o dry cough since 4 days
No h/o fever
No H/o burning micurition
H/o urgency to urination, increased frequency of urination.
Past HISTORY:
He has no history of hypertension and diabetes
No h/o asthma, epilepsy, tuberculosis.
No previous hospitalizations
Personal history:
He is an elderly male not doing any work from past 15 years .he terminated his work as a farmer as ageing . In home he gets up at 6 ,do his daily routine activities and sit quietly.
Apettite-decreased
Diet- mixed
Bladder- decreased
Bowel -normal
Addictions- Smoking-stopped 15 years ago
Alchol-stopped 1yr ago
Family history: No significant
Treatment history: blood transfusion 1 month back
Urethral striture dialation
General examination
Patient is conscious,cohorent , cooperative well known with time, place, person
He is well built and moderately nourish
Pallor present
Lymphadenopathy-right side
Peadal.edema- bilateral peadal edema with pitting type
No cyanosis, clubbing,icterus
VITALS :
On 30 march
Temp : 98.6F
Pulse rate-80bpm
Blood pressure :130/90mmhg
Respiratory rate :20 cpm
Spo2 : 96%
SYSTEMIC EXAMINATION
CVS :
on inspection :
No visible heart pulsations
Palpation:
Apex beat at 6th intercoastal space
Auscultation: S1,s2 are heard
Rhythm regularly irregular
Respiratory system:
Inspection: chest shape normal,
Breath movements -abdominal thoracal
Dyspnea: present
Palpation: trachea -central
Percussion: dullness
Auscultation: crepts +
In infra axillary ,infra scapular area and Inter scapular area
Wheezing heard in Supra scapular area
Vesicular breath sounds
Abdominal examination:
CNS: no focal neurological deficit
Sputum culture - no growth
CBNAAT culture report -awaiting
Day 2-
S: c/o hip pain , stools not passed
O: O: Pt C/c/c
Bp- 130/70mmhg
PR-86bpm
CVS: S1s2+
Rs: BAE+,crepts+ in left ISA, right ISA &IAA, wheeze+
CNS: NAD
P/A: soft , Nontender
I/o: 1000ml /600ml
GRBS: 93mg/dl at 8 am
A: Dilated cardiomyopathy (EF-46%) HFMEF
With s/p stricture dilation (1week back)
B/L syn-pneumonic effusion ?
With AKI
with Rt- LL filariasis (since 4yrs)
P:
1. Fluid restriction <1.5 lit /day
salt restriction <2gm/day
2. Inj. Augmentin 1.2gm IV/TID
3. Nebulization with Duolin 4th hrly, budecort 6th hrly
4. Inj. Lasix 40mg Iv/BD
5. Tab. Azithro 500mg po/oD
6. T.Met XL 25mg po/od
7. T.ecospirin AV 75/100mg po/Hs
8. T.Montair LC po/od/HS
9. T. Ultracet 1/2tablet PO/QID
10. T.pan 40mg po/OD
11. Syp. Grillintus BM 10ml po/TID
12. Monitor vitals 6th hrly
S: SOB decreased, stools passed , decreased hip pain , cough decreased
O: Pt C/c/c
Bp- 130/80mmhg
PR-74bpm
CVS: S1s2+
Rs: BAE+,crepts+ in left ISA, right ISA &IAA
CNS: NAD
P/A: soft , Nontender
I/o: 1200ml /750ml
GRBS: 89mg/dl at 8 am
A: Dilated cardiomyopathy (EF-46%) HFMEF
With s/p stricture dilation (1week back)
B/L syn-pneumonic effusion ?
With AKI
with Rt- LL filariasis (since 4yrs)
P:
1. Fluid restriction <1.5 lit /day
salt restriction <2gm/day
2. Inj. Augmentin 1.2gm IV/TID( day3)
3. Nebulization with Duolin 4th hrly, budecort 6th hrly
4. Inj. Lasix 40mg Iv/BD
5. Tab. Azithro 500mg po/oD
6. T.Met XL 25mg po/od
7. T.ecospirin AV 75/100mg po/Hs
8. T.Montair LC po/od/HS
9. T. Ultracet 1/2tablet PO/QID
10. T.pan 40mg po/OD
11. Syp. Grillintus BM 10ml po/TID
12. Monitor vitals 6th hrly
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