General medicine case

 

GENERAL MEDICINE CASE DISCUSSIONS 


Amisha Jaiswal

Roll no. 03

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 patient’s clinical problems with collective current best evidence-based inputs. This is the E-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.

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 diagnosis and treatment plan.


September 22, 2021
65 year old male, farmer by occupation resident of nalgonda, stopped working 6 months ago, in view of generalized weakness,presented to the opd with chief complaints of fever since 5 days(low grade, intermittant and associated with chills). C/O weakness of right upperlimb and left lower limv since 4 days. B/L knee pain. C/O Abdominal distension and facial puffiness ,B/L pedal edema since 4 days. 
No sob, chest pain, palpitations, orthopnea. 
C/O giddiness and loss of appetite.
H/O loose stools 3 days ago(10-12 episodes /day for 2 days, black coloured stools) whhich subsided now associated with pain abdomen in umbilicus. 
No vomitings, headache, cough. No decreased urine output.C/O burning micturition. No h/o trauma,seizures.

PAST HISTORY :
NO H/O DM, HTN, TB, Asthma, CVA, CAD. 
NO H/O previous renal issues. 
H/o covid pneumonia 8 months ago, subsided with in 2 days. 
H/o fall 2 years back on right hand, implant placed. 
H/o typhoid and liver issues which subsided with medication. 

PERSONAL HISTORY :
appetite :lost
Bowel and bladder regular
Sleep decreased 
Addictions:chronic alcoholic 90ml/day
Chronic chutta smoker.

GENERAL EXAMINATION :
patient is c/c/c.
Temp:Afebrile
Bp:70/50 mm Hg
PR:60 bpm
Rr:18 cpm
Spo2:98%at RA
GRBS:104 mg/dl
No pallor, icterus, clubbing,lymphadenopathy,cyanosis.
Edema present. 

SYSTEMIC EXAMINATION :
CVS:S1,S2 heard, no murmurs 
RS :BAE +,NVBS heard. 
P/A:Distended.
No tenderness, palpable masses,bowel sounds heard. 
CNS:
Power             Rt.            Lt
             
          UL.        3/5.          5/5
          LL.          4/5.          3/5

PROVISIONAL DIAGNOSIS :
?AKI on CKD secondary to Acute GE
Fever with thrombocytopenia with bleeding manifestations. 








INVESTIGATIONS:
HB:11g/dl
TLC: 10,700
PLT: 81000
ESR :7mm/hr

S. CREAT:8.8
URIC ACID:7.8
TB:1.3

Na :135
K :2.6
Cl :98

Ns1  antigen :negative 






PROGRESSIVELY DECREASING THROMBOCYTOPENIA
 
PLAN OF CARE:
IVF:NS,RL @ 50 ml/ hr
Inj. Pan 40mg iv/OD
Inj. Piptaz 4.5g/iv/stat--->2.25g iv/qid
Inj. Lasix 40mg iv/bd
Tab. Pcm 650 mg po/sos
Tab. Doxy 100mg po/bd
Tab. Nodosis 500mg po / tid
Tab. Shelcal 500mg po/OD
INJ. Optineuron 1 amp. in 100 ml NS IV /OD


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