Case presentation 4

 26.10.21

This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-log also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.

Chief complaint:

A 50 year old male presented to the OPD with chief complaints of nausea, Facial puffiness, reduced urine output and Pedal edema and decreased appetite.

History of present illness:

Patient is a toddy climber by occupation.Patient was apparently asymptomatic 2 years back.he then developed pain in legs  and took some pain killers for one year. He later developed generalised swelling.he was taken to hospital in hyderabad.he got his serum creatinine level checked which was elevated and prescribed diuretics.serum creatinine level had increased even when he was on treatment.every 2 month report of serum creatinine showed an increase in level .he was treated there for many months and due to financial and travelling issues of the family he got admitted to KIMS .

Past history:

Not a know case of diabetes, hypertension .

Personal history

Pt takes mixed diet with decreased appetite.pt has decreased urine output with regular bowel movements.

Pt consumes 180 ml of alcohol every day but stopped since one year .

Family history:

No similar condition is seen in any member of the family.

General examination: 

signs of Pallor,no signs of cyanosis,icterus,clubbing,lymphadenopathy and signs of bipedal edema.

Vitals:

Temperature: afebrile

Pulserate:92 beats per min

Respiratory rate:20 cycles per min

BP:140/90 mm of hg

Systemic examination:

CVS:

no thrills,no cardiac murmurs,

 S1 and S2 are heard

Respiratory system:

No dyspnoea and wheezing

Centrally positioned trachea,vesicular breath sounds

Abdomen:

schaphoid shape of abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.

CNS:

Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves

Glasgow scale 15/15 

Provisional diagnosis:

1.Chronic renal failure due to analgesic Nephropathy 

2.DM since admission  

3.HTN since 6 months undiagnosed till admission 

4.Moderate anaemia 

Investigations:

Treatment:

TAB. LASINO 40mg.PO/BD

TAB. NICARDIA 20 mg PO/BD

TAB. PAN 40 mg PO/BD

TAB. OROFER xT PO/BD

TAB .NODOSIN 500mg PO/OD

INJ ERYTHROPOIETIN 4000 IU/SU/weekly once

TAB SHELCAL CT PO/BD

BP/PR/RR CHARTING