46yr male working in welding shop came for haemodialysis
28/08/22
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
The patient came with SOB grade 4 and has bilateral pitting type of pedal edema since 6 months .
HOPI
the patient was apparently asymptomatic 6.months back and then developed bilateral pedal edema which once pitting and upto knees Associated with facial puffiness.then his baseline creatinine was 2.0 so managed conservatively for 4 months. Then he went to NIMS and was initiated to haemodialysis. Total 16 sessions of haemodialysis last session of haemodialysis was on 20/8/22
PAST ILLNESS
CKD since 3 months
hypertension since 6 months and on medication
Diabetes type 2 since 8 years and on medication
TREATMENT HISTORY
diabetes yes
Hypertension yes
No CAD,asthma
TUBERCULOSIS yes (10yrs ago )
No chemoradiation blood transfusion and surgeries
PERSONAL HISTORY
Married
occupation gas welding
Appetite normal
Mixed diet
Irregular bowel
normal micturation
He was alcoholic but stopped 3 yrs ago
FAMILY HISTORY
No diabetes ,hypertension, CAD,stroke , cancer, TB ,asthma
PHYSICAL EXAMINATION
GENERAL
conscious
pallor present
No icterus
No lymphedemopathy
No clubbing of fingers
Edema present
No malnutrition
No dehydration
VITALS
temperature afibrial
Pulse rate 78 bpm
Respiration 20/min
BP 150/70
Spo2 100%
GRBS 154mg%
SYSTEMIC EXAMINATION
no trills
No cardiac murmers
S1 s2 present
RESPIRATORY SYSTEM
Dyspnoea present
No wheezing
Centrally placed trachea
Vesicular breathing sounds
ABDOMEN
obese
No tenderness and palpable mass
Normal hernial orifice
No free fluid
Normal bowel sounds
Liver and spleen palpable
CNS
conscious
Normal speech
No neck stiffness
No kerning's sign
Cranial nerves ,motor system ,sensory system ,Glasgow scale HMF(higher mental function) intact
Reflexes
No finger nose in coordination and knee heel incordination
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