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




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