Case history-1
Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A 37 year old male driver by occupation came to OPD with chief complaints of shortness of breath,pedal edema, decreased urine output since eight months.
HISTORY OF PRESENT ILLNESS:
Patient is a driver by occupation residing in Damer.
Patient was asymptomatic four years ago.
He had decreased appetite,flanks pain for which he visited hospital.He had history of deranged renal function tests.
Patient had two sessions of hemodialysis and is on conservative management for four years.
Eight months ago patient came to casualty with complains of shortness of breath, pedal edema and decreased urine output for which hemodialysis was done.
HISTORY OF PAST ILLNESS:
Patient is a known case of hypertension since eight months.On tablet nicardia 10mg PO/BD.
PERSONAL HISTORY:
Appetite: normal
Diet:mixed.
Micturation: normal
Socio-economic: moderate
Patient used to consume alcholol four years ago
GENERAL EXAMINATION:
The patient was concious, cooperative, coherent and well oriented to time,place and person.
No icterus,cyanosis and clubbing.
Edema of feet and pallor seen.
VITALS:
Temperature:afebrile.
B.P:140/70mm/hg.
Respiratory rate:17/min.
PR:98%at room temperature.
CVS examination:
S1&S2 heard,no yhrills,no murmurs.
RESPIRATORY:
Vesicular breath.
Trachea in central position.
No wheezing.
No dyspnea
ABDOMEN:
Shape:scaphoid.
No tenderness.
No palpable masses.
Normal hernial orifices.
No free fluid.
Not palpable spleen
No bowel sound heard
CNS:
Concious and normal speech
Normal gait
Sensory symptoms are normal
Motor systems are normal
Cranial nerves are normal
INVESTIGATIONS:
Fluid restriction:less than 1.5ltres per day
Salt restriction<2gm/day
Tab.Nicardia 20mg PO/BD
Tab.Arkamine0.1mgPO/BD
Tab.Nodosis 500mg PO/BD
Tab.livogenPO/BD
Tab.shelcal C5 PO/BD
Inj.erythropeitin 4000I.U SC weekly twice
Bp monitoring.
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