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:
X-ray:
ECG:
Hemogram on day 2
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