A 57 year old male with complaints of generalised body weakness,pain over epigastrium......

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians  verbal 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 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.

CHEIF COMPLAINTS

Since 5 days : 

Generalized body weakness 

       Pain over upper abdomen 

       Bilateral pedal edema 

       Burning sensation of both soles

- SOB at rest since 3 days


HISTORY OF PRESENT ILLNESS 



- Patient was apparently asymptomatic 2 years ago then he developed pain in the foot for which he went to a local hospital and was on some pain killers ( unknown) for about an year later he felt relieved and discontinued the drug.
- After few days again he felt pain and went to a hospital during investigations he was diagnosed as kidney failure. He used some medication for it
- Then, 5 days ago he developed generalised body pain which is aggravated on exertion and relieved on medication.
- He also experienced burning pain over epigastric region which is also aggravated on exertion and relieved on medication.
- Fever was also present with chills and rigors.
- Bilateral pedal edema was developed which aggravated on walking and relieved on rest.
- Burning sensation of both soles which is present through out the day and SOB at rest.
- Nausea and giddiness since yesterday.


HISTORY OF PAST ILLNESS


K/c/o Chronic kidney disease

( Use of NSAID'S for 1 year due to pain near 1st metatarsal joint and foot )


Diabetes - No


Hypertension - No


TB - No


Asthma - No


Epilepsy - No


CVD - No


Chemo/Radiation Exposure - No


Surgical history - Nil



FAMILY HISTORY


not significant


PERSONAL HISTORY


Diet - Mixed


Appetite - lost since 10-15 days


Bowel and bladder - Regular movements 


Allergies - No


Addictions - Chewing tobacco


- 90 ml of whiskey occasionally (Once in a month) but stopped 4 months ago 



GENERAL EXAMINATION : 

GENERAL EXAMINATION














SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

 Dyspnoea , Wheeze - Present 

Breath Sounds - vesicular


ABDOMEN :




Shape - Scaphoid

No Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard



CNS : Normal

- Patient is Consious, Coherent, Well oriented to time place and surroundings.


INVESTIGATIONS :





27/8/22-










30/8/22 -

HIV 1/2 Rapid - Non reactive

HBsAG Rapid - Non Reactive

Anti HCV Antibodies Rapid - Negative

Blood group - B Negative



31/8/22 -







1/9/22 -










 TREATMENT

30-08-2022

Diagnosis : CHRONIC RENAL FAILURE 

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


31-08-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever and chest pain

On examination : 

Patient is C/C/C

BP : 120/60 mm of Hg

PR : 82bpm

CVS : S1, S2 present

 RR : 22 cpm

RS : BAE +

P/A soft 

CNS : NAD

Temperature : 101°F

GRBS : 97 mg/dl

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


01-09-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever , left side chest pain and left knee , ankle pain.

On examination : 

Patient is C/C/C

BP : 110/60 mm of Hg

PR : 76bpm

CVS : S1, S2 present

 RR : 24 cpm

RS : BAE +

P/A soft  and non tender

CNS : NAD

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 



02-09-2022

Diagnosis : CHRONIC RENAL FAILURE with chest pain

On examination : 

Patient is C/C/C

BP : 110/80 mm of Hg

PR : 76bpm

CVS : S1, S2 present

 RR : 20 cpm

RS : BAE +

CNS : NAD


Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 







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