This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent
Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input
This Blog also reflects my patient-centred online learning portfolio.
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.
CONSENT AND DEIDENTIFICATION :
The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
CASE DETAILS:
IP NO 202410586
AGE 66 YEARS MALE
PRESENTING COMPLAINTS:
A 66 year male, presented to nephrology opd with complaints of:-
1. Swelling of bilateral lower limbs since 3 months.
2. Difficulty in breathing since 1 week.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year ago, then he had fever with chills for which he sought for consultation and was found to be having high blood pressure; and started on antihypertensive medications, but not adherent to medication.
3 months ago, he developed odema in the legs which was insidious in onset, gradually progressive, aggravated on walking, standing and travelling but relieved on rest. Initially the odema was till the ankle later it progressed to the knee and thigh; which is pitting type, not associated with pain, erythema, itching.
History of difficulty in breathing since one week which was insidious in onset, gradually progressive, initially he experienced difficulty in breathing upon doing work (more than his physical activity); but now he is complaining of difficulty in breathing on doing regular work, orthopnea present.
No complaints of chest pain, palpitations, PND.
Complaints of nausea, History of decreased urinary output
No, complains of fever, Nausea vomiting
PAST HISTORY:
Hypertension since one year on Tab Nicardia 20 MG once daily.
No other comorbidities.
PERSONAL HISTORY:
Appetite decreased
Diet mixed
Sleep adequate
Bowel moments Regular
Decreased urinary output
Addictions
Alcoholic since 20 yrs occasionaly stopped one yr back
Smoker: smokes 3 Bidis every day stopped one yr back
ALLERGIC HISTORY:
No allergies
General examination
Patient was conscious coherent cooperative well oriented with time and place
Temp afebrile
BP = 160/80 mmHg
PR = 80 bpm
RR = 24 cpm
Spo2 = 98 % @RA
Pallor present
No icterus , cyanosis , clubbing , lymphadenopathy
Bilateral pitting type of pedal edema till knee.
System examination
Cvs = s1s2 heard
Rs = bae +
P/A = soft and Nt
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