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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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.
A 70 yr old male, resident of vuttepally, nalgonda, came with chief complaints of
SOB since 1 month and pedal edema since the past 5 days
HOPI
Pt was apparently asymptomatic 1 month back, then he developed SOB grade 4 which was associated with facial puffiness and b/l pedal edema for which he was taken to a private hospital at alalya
He was investigated and his hemoglobin was found to be 3.9gm%. he was given 2 PRBC units and was discharged.
5 days ago, then pt. Complained of b/l pedal edema ( pitting type) and SOB.
No h/o of decreased micrurition
No h/o of easy fatiguability
No h/o of bleeding per rectum
No h/o of melena
Pt is not a k/c/o of htn tb DM CAD asthma epilepsy.
He's a chronic alcoholic and daily drinks 90mlsince the past 40yrs
He's also a chronic smoker and smokes one pack of beedi cigarettes since the past 40 years
PERSONAL HISTORY-
Appetite:normal
Diet:mixed
Bowel and bladder:regular
Sleep: adequate
No significant family history.
GENERAL EXAMINATION
On admission.
Patient is conscious coherent cooperative
Pallor present
Icterus,cyanosis,lymphadenopathy are absent
BP: 100/70mmhg
PR:80
RR: 20 cpm
Temp: afebrile
CVS:S1 S2+ pansystolic murmur
RS: BAE+, right infrascapular crepts and rt. Infrascapular wheeze heard.
CNS: NAD
Speech normal
REFLEXES-
RT. LFT
BICEPS-. ++. ++
TRICEPS-. ++. ++
SUPINATOR- ++ ++
ANKLE. -. ++. ++
KNEE-. ++ ++
P/A:soft,non tender
Investigations
On 11/9/22
On 12/9/22
On 13/9/22
Xray
TREATMENT -
1. Inj Lasix 20mg IV BD
2. Inj Optineurin IN 100ml NS IV
3. T. Ecosprin AV Po OD
4. Nebulization with Budecort
Comments
Post a Comment