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.
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 62 year old male came to the OPD with chief complaints of
CHIEF COMPLAINTS:
Pedal edema since 1 month
Decreased urine output since 1 month
Fever since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 years back then developed pedal edema, shortness of breath, fever, cough and was admitted in a private hospital hyd and diagnosed as renal failure.
In February 2022 patient came to kamineni Narketpalli with chief complaints of shortness of breath and decreased appetite and undergone dialysis under 3 sessions and was on conservative management.
In November 2022, patient came with similar complaints and undergone dialysis here
Now he developed pedal edema since 1 month which is pitting type and complained of fever since 3 days which is continuous ,high grade and associated with chills and rigor.
H/o nausea, vomiting, anorexia on 4th jan night.
Vomiting is non projectile, non bilious, non blood tinged contained food particles associated with nausea in 2-3 episodes.
H/o decreased urine output since 1month
No h/o burning micturition, pain abdomen.
H/o abscess over left medial and infra gluteal region 1 year back.
Came for dialysis ( no regular follow up)
Timeline of events:
PAST HISTORY:
K/C/O Diabetes since 3 years
K/C/O Hypertension since 3 years and on medication for both
Patient had a history of knee injury 3 years back for which he undergone surgery.
N/K/C/O CAD, epilepsy, asthma, Tuberculosis.
No history of any blood transfusions.
FAMILY HISTORY: No significant family history
PERSONAL HISTORY:
DIET: Mixed
APPETITE: Decreased
SLEEP: Adequate
BOWEL MOVEMENTS: Regular
BLADDER MOVEMENTS: Decreased urine output
ADDICTIONS: Drinks toddy occasionally
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative Well oriented to time, place and person
OP COMPOUND POISONING 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 inputs on the comment box A 65 year old male patient came to casualty with Consumption( profenofes) OP compound around 40 ml on 3/2/21 at Chityala Patient was brought to casualty at 4.30 p. m. On 3rd feb H/o 2episodes of vomitings No h/o involuntary micturition/loose stools 7th feb He also complained of left leg pain He also complained of dry cough and chest pain PAST HISTORY N/k/c/o DM,HTN,CAD,Asthma PERSONAL HISTORY Diet:mixed Appetite:normal Sleep: adequate Bowel an...
This is an online E log book to discuss our patient's de-identified health data shared after taking his 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 inputs. CHIEF COMPLAINTS A 13yr old boy came to old with chief complaints of yellowish discoloration of the eyes, yellowish green coloured vomitings and also had yellow coloured urine since 9days. Patient history : At birth: Patient developed jaundice and it resolved spontaneously At 8 months: He had altered bowel movements ,for 1 week he had loose stools and another week he had normal consistency.later he had loose stools every day for 2-3 days during which he became cachetic.He got admitted in hospital and they mentioned as suspected case of celiac disease,chronic diarrhoea,chronic malabsorption. He was treated wi...
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