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 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 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
D.Santhosh (Internee)
CHEIF COMPLAINTS :
Patient came with complaints of ..
- Burning micturition since 2 months.
- Pain abdomen since 2 months.
HOPI :
Patient was apparently asymptomatic 2 months back, then she had ..
- Burning micturition which was insidious in onset and gradually progressive in nature - no aggravating and relieving factors.
- Associated with pain abdomen since 2 months; pain abdomen increased by taking food.
- H/O pain in both limbs since 2-3 yrs
along with h/o swelling of both lower limbs since 2-3 yrs,
- Edema- pitting type, extended up to knee, relieved on lying down.
- No h/o fever, chestpain, palpitations; Orthopnea+
- Decreased urine output- taking lasix 20 mg since 4 years.
- Heaviness in chest after intake of food.
PAST HISTORY:
K/C/O DMT2 since 7 yrs - on medication.
- using T.Glicazide 5mg OD
K/C/O HTN since 7 yrs - on medication.
- using T .Telma 40mg OD
K/C/O CAD- Angioplasty done 7yrs back
- using medication
N/K/C/O TB, epilepsy, asthma, thyroid disorders and CVA.
PERSONAL HISTORY :
Diet- mixed
Appetite - Normal
Bowel movements- Decreased (constipation)
Bladder - Decreased urine output.
Addictions - stopped smoking 10yrs back.
FAMILY HISTORY :
Insignificant
GENERAL PHYSICAL EXAMINATION :
Patient is conscious coherent and cooperative and well oriented to time place and person.
No signs of pallor, icterus, cyanosis, lymphadenopathy and edema.
Vitals at presentation
Temp - afebrile
PR - 88bpm
RR - 18 cpm
BP - 160/100 mmhh
Spo2 - 98%
SYSTEMIC EXAMINATION :
CVS
S1 and S2 heard, no murmurs, JVP-? raised
RR
BAE+ , NVBS
CNS - NAD
P/A - Soft and non tender
INVESTIGATIONS
HEMOGRAM
RFT
ULTRASOUND REPORT
ECG
DIAGNOSIS
? Diabetic neuropathy with H/o Acid peptic disease( since 7 yrs)
- UTI (complicated) with?diabetic cystopathy under active bladder.
- K/C/O T2DM, HTN, CAD (since 7yrs)
TREATMENT
- T Pregablin 75mg PO/HS
- SYP CITRALKA in 1glass water PO/BD
- Tab glipizide 5mg PO/OD
- Tab Telma 40mg PO/OD
- Tab Lasix 20mg PO/OD
- Tab Clopitab 75mg PO/HS
- Tab Amitryptiline 10mg PO/OD
- Tab DULCOLAX 2 tabs PO/HS
- Tab Pantop 40mg PO/OD
- Tab Tamsulosin PO/OD
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