Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
15/08/2022
17/08/2022
2D Echo:
USG:
Case Scenario:
A 63 year old male patient has come to the hospital with chief complaint of decreased urine output, red coloured urine and pedal edema since 5 days.
Chief Complaints:
- decreased urine output since 5 days
- red coloured urine since 5 days
- pedal edema since 5 days
- abdominal discomfort and constipation since 4 days
History of present illness:
- 4 years back patient developed gradual decrease in urine output and retention with abdominal discomfort and shortness of breath when he was diagnosed with benign prostatichyperplasia/ obstructive uropathy, following which an unknown surgical procedure was done. (no documents available)
- for the next 2 years he was asymptomatic but then he again developed thin stream of urine following which he was put on Foley's catheter for 2 years, changing every 7 to 10 days.
History of past illness:
- patient was apparently normal 11 years back when he had right knee joint pain & swelling following which he was diagnosed with Hematoma and unknown surgical procedure was done (Documents unavailable).
- 4½ years back his elder son had financial issues with him and under alcohol influence fought with him and he fell on rocks and had a spinal injury following which he had weakness of all four limbs and was unable to walk. Following which with conservative management, eggs and fish, he regained his power gradually over 2 months; initially he was able to walk with support ans later able to do his daily routine activities including farming.
- no known history of diabetes, hypertension, CAD, asthma, tuberculosis
Personal History:
- married
- normal appetite
- mixed diet
- bowels: constipation
- micturition: abnormal - burning
- no known allergies
- no known addictions
Family History
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Physical Examination
- height: not taken
- weight: 45 kgs
- BMI: not taken
- pallor present
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- edema of feet:
- no malnutrition
- no dehydration
Vitals
- BP: 100/80 mm Hg
- Pulse: 95bpm
Systemic Examination
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vehicular
Abdomen
- shape: distended
- no tenderness
- no palpable mass
- no bruits
- free fluid present
- umbilicus: slit like
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- bowel sounds heard
- genitals: normal
- speculum examination : normal
- P/R examination :
no anal tugs/ fissures/ fistula
hard stool pellets present
anal tone normal
no palpable mass
prostatomegaly seen
no blood staining noted
Central Nervous System
-Higher mental functions : intact
-Patient is conscious, coherent and cooperative and well oriented to time , place and person .
-Cranial nerve examination: intact
-Motor system:
Tone - Right left
Upper limb Hypotonic Hypotonic
Lower limb Hypotonic Hypotonic
Power - Right left
Upper limb 2/5. 3/5
Lower limb- 2/5 2/5
Reflexes- Right left
Biceps - - +++
Triceps +++ +++
Supinator - +++
Knee - ++
nkle - ++
plantar dorsiflexion dorsiflexion
-Sensory examination: normal
-Gait : cannot be accessed
Investigations:
11/08/2022
12/08/2022
ECG:
Treatment:
-Inj Lasix 40mg / iv / TID
-Inj PAN 40 mg / iv / TID
-Inj Optineuron lamp in 100ml /NS/ iv / OD
-Tab Nodosis 500 mg /PO/ BD
-Tab shelcal 500 mg /PO/ BD
-Ecosporin 75/ 10 mg /PO/OD
-Fluid and salt restriction
-BP / PR / Temp monitoring