A 67 year old man came to the opd with fever, vomiting, swelling abdomen.

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 67 year old man who is a barber by occupation from Miriyalguda came to the opd with complaints of shortness of breathbreath since 1 week. . Fever since 4 to 5 days. 

Associated complaints

He also has pain in the left lower segment of abdomen and swelling in that region

He also complains of motions since 4 days and breathlessness since 4 days after admition. 

The pain is not continuous, dragging typer and non radiating. 


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 week back. Then he developed edema in his feet on standing up. When he took rest, the edema and pain wasn't there but aggravated on work. 

7 months back. He had the same problem. He visited a local RMP in nalgonda. . They did a dialysis(spent in patient language) and he recovered. 

2 to 3 months back.. Burning micturition and fever was developed by the patient. 

He went to a local RMP in miriyalyuda

They did a dialysis and fluid theraptherapy

He was also given some antibiotics

Later he developed cold fever,  breathlessness

He then presented to kamineni hospital. 


History of past illness


No diabetes

No hypertension

No epilepsy

No asthma

No tuberculosis

No past history of surgeries

No blood transfusion

Personal histort

Mixed diet

Since 7 months.. Following vegetarian diet. 

Married for 50 years

General exam

Patient is consious, coherent and coopererative

Well versed with time space and people. 

Palor absent

Icterus absent

No lynphadenopathy

No central cyanosis

No peripheral cyanosis

Pedal edema present putting type


Treatment protocol

Inj lasix 40 mg i. V stat

Nebulisation stat

Inj neonol 1gm i. V SOS

TAB DOLO 650 MG BD

OLMESARTAN

MONITOR BP. PR. TEMP. 4 HOURLY

START CATHETER




Comments

Post a Comment

Popular posts from this blog

MEDICAL CASE LOG

Hello everyone.  This is Souraja Acharya, a medical student from kamineni Institute of medical sciences.  Medicine is vast. So vast of an ocean it is that sometimes we lose track of how we are progressing.  Hence, this is my attempt to bring to you all of my learnings of General medicine. All in one place.  I hope I can bring to you this and share with you my learnings while I am on my journey of Medicine.  So let's start..  Welcome to my journey people.  CBBLE stands for case-based blended learning ecosystem- which aims in practicing precision medicine ,that focuses on meeting patient requirements accurately, optimizing patient outcomes, and reducing under-/overdiagnosis and therapy. PaJR- Patient journey records -"The Patient Journey Record system (PaJR) is an application of a complex adaptive chronic care model in which early detection of adverse changes in patient biopsychosocial trajectories prompts tailored care, constitutes the cornerstone of the model". While you
Read more

A 75 year old man presented to the OPD with pain swelling and blisters on the ankle and leg on left side.

Image
Hello everyone. I am Souraja Acharya, a third proffesional MBBS students at kamineni.  This is an online E logbook 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 from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs CHIEF COMPLAINTS A 75 year old man who is a farmer by occupation from Villamla presented to the OPD with complaints of pain and edema in the right ankle and foot which gradually progresses upward towards the groin. He also complaints of immobility in the foot.  HISTORY OF PRESENTING illness The patient developed the same situation 2 years back when a thorn pricked him on the medial side of his left leg and led to an infection.on visiting a local RMP, he was put on medication and the site was properly cleaned with warm water.
Read more

A 45 year old woman with no appetite, nausea, weakness in both legs

Image
This is an online E logbook 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 from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs PRESENTING COMPLAINT -A 45 year old woman presented to casualty with complaints of excessive weakness and fatigue in both her legs and also her upper limbs. Due to this weakness, she fell down when attempted to walk and hence brought to the hospital.  ASSOCIATED COMPLAINT She also complains of loss of appetite and feeling of nausea when she tried eating.  She also complains of moderate weakness in her entire body.  HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 5 days back.4 days back, on Monday (29/05/23)  She had weakness in her legs which started in the morning and gradually increased thr
Read more