Hi, I am Manasvi Peddineni, 5th sem medical student. This is an 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 centered 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint: 75M, resident of Nalgonda came to opd with chief c/o
- burning micturition since 10 days
- pedal edema since 1 month
- decreased appetite since 10 days
History of Presenting Illness: Patient was apparently asymptomatic 2 years ago when he developed burning micturition and pedal edema which was diagnosed as renal failure and was put on 4 to 5 sessions of hemodialysis. He remained asymptomatic until 10 days back when he developed
- burning micturition which was insidious in onset, gradually progressive, whitish discolouration of urine present, relived on taking medication, 5 to 6 times a day
- B/L pedal edema, since 1 month, insidious onset, gradually progressive, pitting type
- decreased appetite since 10 days
Past History: h/o similar complaints 1 year ago, which was diagnosed as urinary tract infection and he was treated with unspecified medication
N/k/c/o DM, HTN, CAD, TB, asthma, epilepsy, thyroid disorders
Surgical History: not significant
Family History: not significant
Drug History:
TAB. Furosemide
TAB. nitrofurantoin
Personal History:
- normal appetite
- vegetarian diet since
- regular bowel movements
- burning micturition
- no known allergies
- occasional alcoholic, stopped 4 years ago
General Examination:
I have examined the patient after taking prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time, place and person
- well built and adequately nourished
- pallor present
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- pedal edema present
- no malnutrition
- no dehydration
Vitals:
temperature afebrile
PR: 92 bpm
RR: 22 cpm
BP: 130/80 mm Hg
Fluid Intake and Urine Output
Total Input: ml
Total Output: ml
Fever Chart:
Systemic Examination:
CARDIOVASCULAR SYSTEM
Inspection :
-Shape of chest: elliptical
-No engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
RESPIRATORY SYSTEM
Patient examined in sitting position
Inspection:
- Upper respiratory tract - oral cavity, nose & oropharynx appear normal.
-Chest appears Bilaterally symmetrical & elliptical in shape
- dyspnea if present
-Respiratory movements appear equal on both sides and it's abdominothoracic type (males).
-Trachea central in position & Nipples are in 5th Intercoastal space
-No dilated veins,sinuses, visible pulsations.
Palpation:
-All inspiratory findings confirmed
-Trachea central in position
Percussion:
Resonant
Auscultation:
-Supraclavicular- (NVBS) (NVBS)
-Infraclavicular- (NVBS) (NVBS)
-Supramammary- (NVBS) (NVBS)
-Inframammary- (NVBS) (NVBS)
-Axillary- (NVBS) (NVBS)
-Infra axillary-(NVBS) (NVBS)
-Suprascapular- (NVBS) (NVBS)
-Interscapular- (NVBS)
-Infrascapular- (NVBS)(NVBS)
ABDOMEN
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- bowel sounds heard
- genitals:
- speculum examination :
- P/R examination :
CENTRAL NERVOUS SYSTEM
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: no
- knee heel in coordination: no
- gait: normal
Investigations:
Provisional Diagnosis:
Treatment: