44 yr male with CKD,CAD and hypertension

 23/08/2022

 Eblog4

Hi, I am shaik Ayesha , 3rd 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 patient's 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 the 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. 

CHIEF COMPLAINTS:

A 44 yr old male came was admitted in the hospital on 28/07/2022 with complaints of shortness of breathe,orthopnea, PND(paroxysomal nocturnal dyspnea), and decreased urine output since one month. 


HISTORY OF PRESENT ILLNESS :

He was apparently asymptomatic one month ago and developed shortness of breathe grade '4 , orthopnea and decreased urine output.

PAST ILLNESS:

Post CPR status revived 

DM since 15 years 

Hypertension since 3 years


EXAMINATIONS:


Pallor - yes


No icterus 


No cyanosis 


Oedema present


No lymphadenopathy 


No malnutrition 


No dehydration 


VITAL SIGNS 


GRBS 160 mg %


Heart rate 88bpm


Respiration 14 per minute 


BP 110/70 mm of hg 


SpO2 98% 


Treatment history: 


DM present 


CAD present 


Hypertension present 


No asthma 


No tuberculosis


No antibiotics


No hormones 


No chemoradiation 


No blood transfusion


No surgeries 


PERSONAL HISTORY:


married 


Appetite is normal 


Mixed diet 


Bowels are regular 


Decreased micturition 


No known allergies 


No addictions 


FAMILY HISTORY


no DM 


No hypertension 


No heart disease 


No stroke 


No cancer


No tuberculosis 


No asthma 


No hereditory disease 


No psychiatrist illness 


No sibling history 


SYSTEMIC EXAMINATION 


CVS


No thrills 


S1 S2 present 


No cardiac murmurs 


RESPIRATORY


Dyspnea present


Centrally placed trachea 


No wheezing 

Vesicular breathe sounds 


ABDOMEN 


scaphoid shaped abdomen 


Tenderness is not seen 


No palpable mass


Normal hernial orifice


No free fluid 


No bruits 


Liver is not palpable 


Spleen not palpable 


Bowel sound are present


CNS


conscious 


Normal speech 


No neck stiffness seen 


No kernings sign 


Cranial nerves are normal 


Motor system normal 


Sensory system normal 


Glassgow normal


Reflexes are present 




Cerebral signs: no finger nose in-cordination 


No knee heal cordination 


Normal gait 


Other information: 





22/08/22


 he had fever spike since morning 


Vitals 


BP 160/90mmhg 


Pulse 98 per minute 


s1 s2 present 


BAE present 


Per abdomen soft 


CNS = NFND


23/08/2022 He had no fever 




21/08/2022 at 5:33 am
 ECG ON 27/07/2022
















DIAGNOSIS: 

CKD 

CAD 

Hypertension

Tachycardia 

Abnormal ST segments and short PR int

erval


MEDICATION








24/08/22





25/8/22


The patient was taken for dialysis at 6pm(10th time)

26/8/22



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