A 37 year old with shortness of breath and pedal edema

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 centred online learning portfolio and your valuable inputs on comment box is welcome

 

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.

A 37 year old male, resident of yedadri district and a centring worker by occupation, came to the OPD with the chief complaints of 

• Shortness of breath since 3 months 
• Pedal edema since 15 days 

HISTORY OF PRESENTING ILLNESS :

The patient was apparently asymptotic 3 years ago when he had fever and an episode of giddiness for which he went to the hospital and was diagnosed with hypertension. 

The patient was given telmasartan and was sent home.

 The patient took the medicine for few days but stopped as his relatives and friends told him not to take hypertension medication that early in life as it might lead to problems. 

He used to experience neck pain during some days for which he takes the hypertensive medication apart from that he is not compliant with the medication. 

Patient gives a history of shortness of breath (grade 2 MMRC) and chest pain 3 months back. The chest pain was of stabbing type and was only felt on moving from side to side or bending forward. It was also associated with a swelling over the left side of the chest (left mammary region). For this, he went to the doctor and was given medication. His complaints of pain and swelling  were relieved in 3 days. 

The shortness of breath was not relieved. 

The patient gives history of fever 20 days back which was associated with burning micturition. The fever was of low grade and was intermittent in nature. It was associated with chills and rigor. He has had significant weight loss (the patient’s waist size decreased from 32 to 28 in the span of one month.)

He complains of pedal edema since 15 days. It initially extended till his ankle. Presently it extends up till his knee. 

The shortness of breath has increased to grade 3 MMRC in the last one month due to which he stopped working. 5 days back his SOB increased to grade 4 MMRC. 

PAST HISTORY 

He is not a known case of DM, coronary artery diseases, Asthma, TB, epilepsy. 

PERSONAL HISTORY 

• Diet: mixed
• Appetite: Reduced
• Bowel: normal 
• Bladder : burning micturition 
• Sleep: disturbed 
• Addictions: he has been consuming 90ml of whiskey everyday for the past 15 years. He has been smoking 2 cigarettes per day for the past 15 years. He also chews ghutka.
• Allergies (food/drugs) : nil 

GENERAL EXAMINATION 

•   The patient if conscious, coherent and cooperative 
• He is Moderately built and moderately nourished
• Pallor is present 
• Edema upto the knee joint is seen. It is of pitting type. 
• NO icterus, clubbing, cyanosis, generalised lymphadenopathy  is seen 

VITALS:

• PR: 90bpm
• BP: 150/100mmHg
• RR: 18 cpm
• Temperature: Afebrile

SYSTEMIC EXAMINATION 

CVS: 

• On palpation,

-Apex beat was diffuse and was felt at 6th intercostal space lateral as well as medial to mid-clavicular line. 

-JVP was raised 

-No precordial bulge 

• parasternal heave was felt 

• On auscultation

• S1, S2 heard; no murmurs were heard 

ABDOMINAL EXAMINATION:

The abdomen is scaphoid. 

Tenderness was noticed just below the sternum. 

There is no local raise of temperature. 

There was no organomegaly. 

RESPIRATORY SYSTEM: 

Bilateral air entry was present. 

Vesicular breath sounds were heard. 

CNS: 

No functional deficits were noticed. 

 X-ray: 

Mild pleural effusion and prominent right descending pulmonary artery 

Cardiomegaly 

ECG: 

left ventricular hypertrophy

FUNDOSCOPY: 

Right eye and left eye show grade 1 hypertensive retinopathy changes. 

ULTRASOUND ABDOMEN AND PELVIS:

B/L grade 3 parenchyma disease and mild ascites was seen. 

CUE 

- Albuminuria present

24 hr UPCR sent 

24 hr urinary protein - 1,190 mg/day

24 hr urinary sodium- 227 mmol/day

24 hr urine volume 1300ml

Serum Uric acid- 7.5 mg%

Serum electrolytes Na - 140, Cl 106, K+ 5

Serum creatinine- 5.6 mg/dl

Serum calcium- 9mg/dl

Blood urea - 119 mg/dl

2D echo

All chambers are dilated. 

A 27 year old with abdominal pain

 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 centred online learning portfolio and your valuable inputs on comment box is welcome

 

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.

A 27 year old male patient, who is a driver by occupation and a resident of Chityala came with the chief complaints of 

Abdominal pain since 5 days 

Nausea and committing since 5 days. 

The patient was apparently asymptotic 10 years back. He started drinking at an age of 17 years. He had his first drink (toddy) in a function that he attended. At that time he consumed 2 bottles of toddy. The patient gives history that he faced similar complaints back then that is abdominal pain, nausea and vomiting. For which he was taken to the hospital and was treated. 

Later the patient started drinking occasionally usually with his friends or during festivals (1 bottle)

10 days before the symptoms started the patient gives a history of drinking 1-2 bottle of toddy everyday as it was someone’s wedding/ function.  The day after drinking he would wake up with a hangover and drink 1/4 bottle of toddy to get relieved from the symptoms. 5 days ago the patient gives history of going to a  wedding where he ate “masala rice” and drank 2 bottles of toddy. 

6 hours after this he started experiencing abdominal pain in the epigastric and the umbilical region. The pain was sudden in onset and constant throughout the time. There were no aggravating or relieving factors as such. 

The patient also complains of nausea and vomiting. He has had a vomiting episode everytime he has tried to consume food. 

He also had FEVER which was  low-grade,  intermittent , associated with burning micturition but not associated with chills& rigors cold , cough,  weakness ,joint pains

As his symptoms were not subsiding he went to a hospital in nalagonda, where he was given symptomatic treatment. And was put on NBM. 

He has had 2 loose stool of day 3 and day 4 of symptoms. 

As the patient’s condition was not improving they shifted to our hospital. 

PAST HISTORY 

He is not a known case of DM, HTN coronary artery diseases, Asthma, TB, epilepsy. 

PERSONAL HISTORY 

Diet: mixed

Appetite: NIL 

Bowel: normal 

Bladder : normal

Sleep: disturbed 

Addictions: consumes toddy 

Allergies (food/drugs) : nil 

GENERAL EXAMINATION 

•   The patient if conscious, coherent and cooperative 
• He is Moderately built and moderately nourished 
• NO signs of pallor, icterus, clubbing, cyanosis, generalised lymphadenopathy, pedal edema  is seen 

VITALS:

• PR: 90bpm
• BP: 110/70mmHg
• RR: 18 cpm
• Temperature: 99.4°F

PER ABDOMINAL EXAMINATION :

On inspection : 

The abdomen is scaphoid in shape. The umbilicus was central in position and inverted. 

There were no visible peristalsis, engorged veins, discoloured skin over the abdomen.  

On palpation :

Tenderness is  noted. Muscle guarding is present. 

There is no organomegaly. 

No signs of ascites. 

On auscultation: 

Decreased bowel sounds were heard. 

Respiratory system examination

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 

CVS: 

S1 and S2 are heard. 

No abnormal heart sounds were heard. 

CNS:

No fuctional deficits were noticed. 

TREATMENT : 

IVF : NS , RL @ 100ml/hr 

INJ. ZOFER 4mg IV /BD

INJ.PANTOP 40mg IV/BD

INJ.PCM 650mg po/TID 

INJ.NEOMOL 1g sos(if temp >101 f ) 

INJ. OPTINEURON 1amp in 100ml NS IV/BD

INJ. TRAMADOL 1amp in 100ml NS IV/BD

65 year old female with fever and generalised muscle pain

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 centred online learning portfolio and your valuable inputs on comment box is welcome

 

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.  

A 65 year old female, homemaker by occupation and a resident of Miryalaguda  presented with the chief complaints of 

• Fever since 10 days 
• Generalised body weakness since 10 days 

The patient was apparently asymptotic 5 years back when she went to a hospital for her knee pain and during the general examination was diagnosed with hypertension.  

Tab. Telmesartan 40mg OD was given and the patient has been compliant with the medication till date. 

She went to a hospital for a regular checkup 4 years back and was diagnosed with Diabetes mellitus. She was given tab. Metformin. She was compliant with the medication. The medication was stopped 6 months back as suggested by the doctor after checking her blood sugar levels which were low. 

The patient had complains of pedal edema 1 year back. The edema was noticed till her knee joint. She waited for 2 months for it to subside on its own after which she went to the hospital as it was not decreasing.  On evaluation in the hospital they were informed that the size of the kidneys were reduced and there was protein in the urine. 

She also complained of foul smelling urine during this time but there were no other symptoms such as burning micturition. 

After evaluation the patient was given medication for the kidney pathology which she used till 3 months ago. The patient then stopped the medication without consulting the doctor as there were no symptoms. 

The patient complaints of fever since 10 days. The fever was of low grade (100-101°F) and was associated with chills and rigor. It showed nocturnal variation and was decreased on taking medication. There were no complaints of cough or night sweats. 

The patient also complains of generalised body weakness since 10 days. 

She also complains of foul smelling urine. 

She is not able to get up from her bed to do her normal activities. 

PAST HISTORY 

She is not a known case of coronary artery diseases, Asthma, TB, epilepsy. 

PERSONAL HISTORY 

Diet: mixed

Appetite: decreased 

Bowel: normal 

Bladder : foul smelling urine 

Sleep: adequate

Addictions: nil

Allergies (food/drugs) : nil 

GENERAL EXAMINATION 

•   The patient is drowsy but easily arousable and follows commands. 
• She is Moderately built and moderately nourished
• Pallor is present 
• 
  
  
• Pitting type of pedal edema is seen. 
  
  
• NO icterus, clubbing, cyanosis, generalised lymphadenopathy. 

VITALS:

• PR: 90bpm
• BP: 130/90 mmHg
• RR: 20cpm
• Temperature: 99°F

CVS EXAMINATION:

• On palpation,

-Apex beat was felt in the 5th intercostal space medial to the mid clavicular line. 

-JVP was normal  

-No precordial bulge 

-No parasternal heave

-On auscultation, S1, S2 heard; no murmurs were heard 

RESPIRATORY EXAMINATION: 

• INSPECTION:  bilaterally symmetrical 

-Expansion of chest: Equal on both sides

-Position of trachea: Central

-Supraclavicular and infraclavicular hollowness was not seen 

-No Crowding of ribs 

-No visible scars, sinuses, pulsations

• PALPATION:

-expansion of chest was equal on both sides. 

-Position of trachea: Central

-Vocal fremitus: resonant note was felt.

• PERCUSSION: all lung areas were resonant 
• AUSCULTATION:

• Bilateral air entry was present. Vesicular breath sounds were heard.  
• Vocal resonance: resonant in all areas

PER ABDOMINAL EXAMINATION 

• Soft, non-tender
• No hepato-spleenomegaly was noted

CNS EXAMINATION :

HIGHER MENTAL FUNCTIONS- 

The patient was drowsy. 

Speech and language normal

Memory intact

CRANIAL NERVES  are normal

MOTOR EXAMINATION- 

Normal bulk in upper and lower limbs

Normal tone in upper and lower limbs

Normal power in upper and lower limbs

Gait could not be examined as the patient is drowsy and not being able to stand. 

SENSORY EXAMINATION-

Normal sensations felt in all dermatomes

REFLEXES-

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited.

No meningeal signs were elicited. 

FEVER CHART:

INVESTIGATIONS ON DAY 1 

2D Echo:

 

USG ABDOMEN: 

X-ray: 

ECG:

 

Hemogram on day 2 

A 55 YEAR OLD PATIENT WITH SHORTNESS OF BREATH AND DECREASED URINE OUTPUT.

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 centred online learning portfolio and your valuable inputs on comment box is welcome

 

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. 

 A 55 YEAR OLD PATIENT WITH SHORTNESS OF BREATH AND DECREASED URINE OUTPUT. 

A 55 year old male, farmer by occupation and a resident of rajammagudam, came with the chief complaints of 

• Shortness of breath since 1 year 
• Pedal edema since 3 days 
• Decreased urine output since 3 days. 

HISTORY OF PRESENTING ILLNESS 

• The patient was apparently assymptomatic 3 years back when he was diagnosed with diabetes when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication. 
• The patient was having blurring of vision and dizziness for which he went to the doctor and was diagnosed with hypertension and was given amlodipine. He is compliant with the medication. 
• The patient complains of shortness of breath since 1 year. It was initially of grade 2(MMRC Classification) that is he has to stop to take breath while walking at his own pace. For this he went to a local doctor and was given a tablet (unknown). 

• The shortness of breath has aggrevated to grade 4 MMRC classification that is shortness of breath even at rest 7 days back. 
• The shortness of breath was associated with PND and orthopnea. It was not associated with chest pain or palpitations. 
• The patient also complains of non productive cough since 3 days. 

• The patient has had decreased urine output for the past three days. In the 24hrs before admission he did not have any urine output. 

• He doesn’t have any hesitancy, increased frequency or fullness of bladder. 

PAST HISTORY 

He is not a known case of coronary artery diseases, Asthma, TB, epilepsy. 

PERSONAL HISTORY 

Diet: mixed

Appetite: decreased 

Bowel: normal 

Bladder : decreased urine output 

Sleep: disturbed 

Addictions: nil

Allergies (food/drugs) : nil 

GENERAL EXAMINATION 

•   The patient if conscious, coherent and cooperative 
• He is Moderately built and moderately nourished
• Pallor is present 
• 
  

• 
  
• NO icterus, clubbing, cyanosis, generalised lymphadenopathy, pedal edema  is seen 

VITALS:

• PR: 62bpm
• BP: 110/80 mmHg
• RR: 20cpm
• Temperature: Afebrile

CVS: 

• On palpation:

-Apex beat was diffuse and was felt at 6th intercostal space lateral as well as medial to mid-clavicular line. 

-JVP was raised 

-No precordial bulge 

-No parasternal heave

-On auscultation, S1, S2 heard; no murmurs were heard 

RESPIRATORY EXAMINATION: 

• INSPECTION:  bilaterally symmetrical 

-Expansion of chest: Equal on both sides

-Position of trachea: Central

-Supraclavicular and infraclavicular hollowness was not seen 

-No Crowding of ribs 

-No visible scars, sinuses, pulsations

• PALPATION:

-expansion of chest was equal on both sides. 

-Position of trachea: Central

-Vocal fremitus: resonant note was felt.

• PERCUSSION: all lung areas were resonant 
• AUSCULTATION:

-Bilateral air entry was present. Vesicular breath sounds were heard.  
-Vocal resonance: resonant in all areas

PER ABDOMINAL EXAMINATION 

• Soft, non-tender
• No hepato-spleenomegaly was noted

CNS : intact 

On 19/02/22 : the patient was admitted and dialysis was done. (Indication: metabolic acidosis pH: 7.19) 

On 20/02/22 : the patient had another session of dialysis. (Indication: metabolic acidosis pH: 7.29)