final exam long case

This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome. 
 Chief complaint -
 A 54 yrs old male patient of resident suryapet, shop keeper by occupation came to opd with chief complaint of pedal edema from 1 month and fever from 4 days. 
History of present illness-
Patient was apparantly asymptomatic 6months months back and then he developed  fever   associated with chills , rigor and vomitings. He was admitted in local hospital and was found to have raised creatinine levels and diagnosed as renal failure. He was under observation for 10days and treated . He was on medication for 5months. (Tab dolo650mg, inj zofer4mg , Iv NS, sodocel 500mg)Later one month back he developed pedal edema and before4 days back he developed fever which is intermittent type no diurnal variation , not associated with cough and cold , burning micturition loose stools vomiting , associated with chills and rigors.
History of past illness-
History of NSAID abuse 
H/o Left Hip replacement 15yrs back
H/o Hypertension 5yrs back
N/k/C/O Dm, asthma, CAD, CVA, Epilepsy, Tb. 
Family history-
No significant family history
Personal history
Diet - mixed
Appetite- normal
Bowels - regular 
Micturation- normal
Allergies- no allergies
Addictions- no addictions

Daily Routine- 
6:00 wake up 
7:00 shop
8:30 breakfast
2:00 lunch
9:00 return to home 
10:00 dinner 
11:00 sleep

Physical examination-
Patient is conscious, coherent, cooperative and well oriented to time and place. 
Patient is moderately built and well nourished. 
General-
Pallor is seen 
Edema of feet is seen 
No cyanosis, clubbing, lymphadenopathy, icterus. 
Vitals-
Temperature- febrile
Pulse rate - 98bpm
Bp-170/90mmhg
Rr--15cycles per minute
Spo2- 99%
Systemic examination-
Cvs -
No thrils
No murmurs
S1 , s2 sounds are heard
Respiratory-
Bilateral airway entry is normal
No dyspnoea
No wheezing
Vesicular breath sounds 
Position of trachea is central 
Abdomen-
Shape of the abdomen - distended
No tenderness
No palpable mass 
Liver & spleen are not palpable 
No bruits 
No scars and sinuses
CNS-
Patient is conscious, coherent, cooperative, and well oriented to time and place. 
Speech-normal 
No neck stiffness
Sensory and motor system- normal 
No kerning sign
Investigations-
19-1-2023 ECG
Diagnosis-
CKD on MHD
Treatment-
Tab lasix 20mg 
Tab Metoprolol 50mg
Tab shelcal 500mg
Tab nodosis 500mg
Tab nicardia 10mg
Tab sevalmer 400mg
Inj Erythropoetin 4000 iu S/C twice weekly

Comments

Post a Comment

Popular posts from this blog

a 45 yrs old male patient

Image
 A patient who is 45 yr old male came to OPD with chief complaints of fever since 2 days and slurring of speech since 1 day and pain in both lowerlimbs . HISTORY OF PRESENT ILLNESS     Patient is a daily wage worker by occupation . Patient was apparently asymptomatic 2 years back then his appetite increased( about 5- 6 times a day ) for which he came to KIMS hospital and diagnosed with Diabetes.He used oral hypoglycemic drugs for first 6 months.Then from past 1.5 years he is on insulin.He was a chronic alcoholic since 25 yrs. He consumes more than 180ml / day . Urine output increased since 2 years about 10 times a day.Decreased weight about 25kg since 2 years. Then since 2 days he developed fever which was high grade, continuous and associated with chills and rigor and also presence of neck stiffness and burning Micturition.Patient was also anemic for which he received blood transfusion   He developed slurring of speech since 1 day then he came to hospital the next day HISTORY OF PA
Read more

27 yr old male patient with Acute gastro enteritis

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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.  Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival )  5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing
Read more