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 60 year old man, resident of yedadri district and a palm tree climber by occupation, presented to the hospital with the chief complaints of
- shortness of breath since 6 months
- Pedal edema since 10 days
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 10 years back when he had an episode of dizziness for which he went to a doctor and was diagnosed with hypertension.
The patient was prescribed medication (Cilnidipine) and he is compliant with the medication till date.
The patient has had complaints of shortness of breath since 6 months. It was initially of class 2 NYHA classification (ordinary physical activity results in SOB) and progressed to class 3 NYHA (less than ordinary activity results in SOB). He complains of decreased urine output since 6 months. For which he went to a doctor and was prescribed furesamide. He is compliant with the medication. No other information is available with the patient regarding that visit.
He also has orthopnea and PND.
He has had pedal edema since 10 days which was initially till his ankle joint now involves his entire lower limb as well his upper limbs.
He doesn’t have any complaints of palpitations, chest pain, sweating, cough, fever, burning micturition, loin pain, hematuria.
Past history
He was diagnosed with HTN 10 years back.
He is not a known case of DM, HTN coronary artery diseases, Asthma, TB, epilepsy.
No similar complaints in the past
PERSONAL HISTORY
- Diet: mixed
- Appetite: Normal
- Bowel: normal
- Bladder : decreased urine output since 6 months
- Sleep: disturbed
- Addictions: he used to smoke 1 packet of biddis (15years - 50 years). He used to drink 2 bottles of toddy per day. He stopped drinking toddy when his SOB started i.e. 6 months ago.
- Allergies (food/drugs) : nil
Daily routine :
He wakes up at 6:00 everyday. He brushes his teeth and take a bath and then he has breakfast. He is done with his morning routine by 8:00am. He then takes rest and watches TV. he has lunch at 1:30pm. Following which he takes an afternoon nap. He wakes up at 4:00 and has snacks. He has dinner at 8:30 and sleeps at 9:30 after watching news.
GENERAL EXAMINATION
Patient is conscious, coherent and co-operative; well oriented to time, person, place.
Well built and well nourished.
Pedal edema, pitting type throughout leg upto hip. Pitting type edema over his Right hand upto his shoulder. Mild pitting edema over left hand as well.
Pallor present.
No icterus, clubbing, cyanosis, generalised lymphadenopathy.
- PR: 92bpm
- BP: 140/90mmHg
- RR: 18 cpm
- Temperature: Afebrile
CARDIOVASCULAR SYSTEM:
On palpation,
-Apex beat was diffuse
-JVP not raised
-No precordial bulge
-No parasternal heave
On auscultation, S1, S2 heard; no murmurs
RESPIRATORY SYSTEM
INSPECTION:
bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular areas normal
Spinoscapular distance normal
No crowding of ribs
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Chest diameter: 5:7
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
crepts heard over all lung fields
Vocal resonance: resonant in all areas
PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
EVALUATION
Hb: 9.1gm%
Serum creatinine : 10mg/dL (0.9-1.3mg/dL)
Blood urea : 132mg/dL (12-42mg/dL)
ELECTROLYTES
Serum sodium : 134 mEq/L (136-145 mEq/L)
Serum potassium : 3.4 mEq/L(3.5-5.1 mEq/L)
Serum chloride : 98 mEq/L (98-107 mEq/L)
2D ECHO
TREATMENT :
Tab. LASIX 40 mg PO TID
Tab. PAN 40mg PO OD
Tab. NODOSIS 50mg PO OD
Tab. SHELCAL PO OD
Inj. EPO 4000IU Weekly once
Tab. NICARDIA 10mg PO OD
Discussion:
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