This is 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 patients 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 comment box is welcome .
K.shirisha
Rollno;60,
9th semester
I’ve 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
( All the information have been collabated from patient).
Case discussion;
Following is the view of my case
Case discussion ;
A 58 old male daily wage labourer by occupation came to the hospital .
Chief complaints ; shortness of breath since 1 month.
Decreased urine out put since 1month
Pedal edema since 3 months
Chest pain since 1 month
Facial puffiness since 1 month
History of present illness;
The patient was alright 4 years ago
4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos
2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice
Left upper limb swelling, gradually progressing to current size, since 4 months .
Also developed rt upper limb swelling since 4 days.
Swelling in the left chest region, gradually progressing to current size, since 4 months
Back pain since 2 months, subsided on medication (T. Ultracet)
30 days back - developed
Shortness of breath ,
Grade II-III progressed to Grade IV since 30 days along with orthopnea .
Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.
Even after dialysis, chestpain did not subside
Ecg was done(18/01/22): ST elevations noted in V2,V3,V4
Repeat ecg done (on 19/01/22):
ST elevations subsisded
C/o. generalized body pains
No c/o palpitations, giddiness, cold, cough, burning micturition
PAST HISTORY -
Known case of Hypertension since 4years on Tab nicardia 20mg OD
Not K/C/O TB, Epilepsy, Asthma, CAD.
Personal history:
Appetite- decreased
Diet- mixed
Bowel movement- Regular
Alcoholic stopped 4 yrs ago
Non smoker
On examination:
Pt is C/c/c
No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy
B/L pedal Edema(pitting type) present
Vitals
Pr:94bpm
Bp:120/80
Spo2:97% at RA
Temp - Afebrile
Systemic examination
CVS -
Position of trachea ;midline
No visible pulsations,no raised jvp
Precordial bulge : absent
Shape of chest; bilaterally symmetrical
Upper part of chest swelling is seen
Apexbeat ; left 5th inter costal space1cm medial to mid clavicular line
✓Palpation; no tenderness,no local rise of temperature,all inspectory findings are confirmed nopalpable thrills,parasternal heaves are palpable
✓Percussion ; Heart borders;
Left border; 1.5cm internal to mid clavicular line
Right border of heart; right of sternum at the level of 4th rib
Upper border of heart; cannot be defined as dullness of heart tissue continues with dullness of big vessels
Lower border of heart : cannot be defined ,as it lies in relation with the diaphragm and left lobe of liver below it
✓ Auscultation;
S1,S2 heart sounds heared,no thrills and murmurs
RS - BAE + ,
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose; no DNS,polyp
Pharynx ; normal
✓Lower respiratory tract;
Position of trachea; midline
Position of Apex beat; left5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movement of chest ; normal
✓Palpation ;
Position of trachea,apical pulse is confirmed
No tenderness over chest wall,no palpable added sounds,no palpable pleural rub
Bilateral basal crepitations are present
* Vocal fremitus ; vibrations of chest are equal
✓Percussion;
Resonant note heared,no obliteration on traubes space
✓Auscultation;
BAE-PRESENT
Normal vesicular breath sounds,no wheeze or no adventitious sounds
CNS - NAD
P/A- Soft, non tender,no organomegaly.
Investigations on 02/01/2022:
Repeat xray:
Serology - Negative
Ortho referral for back pain :
Investigations on 08/01/2022:
Serology: negative
Rft:
Ecg:
Xray on 21/01/2022:
Diagnostic pleural tap was done.
Post -pleural tap xray
Pleural fluid LDH 98
Serum LDH 294
Ratio-0.3
Pleural fluid protein-2.0
Serum total protein -5.9
Ratio-0.3
Total count -100cells
Differential count-
80% lymphocytes
20% neutrophils
Transudative effusion
Ortho referral done
ECG on 4/3/22
Chest x ray
5/3/22;
X ray erect abdomen
Serology;
Blood urea
Serum creatinine
Electrolytes
9/3/22
14/3/22
Provisional Diagnosis -
CKD on MHD
Heart failure secondary to coronary artery disease(recent lateral wall MI)
?Spondylodiscitis
Hypertensive since 4yrs
?left upper limb lymphedema (secondary to AV fistula surgery)
Treatment ;
✓ fluid restriction 1.5 litre/ day
✓ salt restriction <2g/day
✓ tab lasix 40mgbd
✓tab metoz 5mg of
✓ tab nicardia 20mgbd
✓ tab arkamine 0.1 mg TID
✓ tab orofer-xt of
✓ tab nodosis 500mg bd
1-*-1
✓ tab shelcal 500mg of *-1-*
✓cap bioD3 0.25 mg of
✓ tab pan-d 40mg of
✓inj erythropoietin 4000u sc once weekly
✓ moniter vitals
12/3/22
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