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.
An 80year old male was brought to casualty with the chief complaints of sob, decreased urine output since 4days,low grade fever and cough since 4 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5days back then he developed pedel edema, decreased urine output,anuria since morning,fever associated with cough and shortness of breath
PAST ILLNESS:
Patient met with an accident(rta)which caused injury to left forearm.Patient used nsaids for pain for almost 6months.
2years ago he got admitted ina local hospital for sob,pedal edema
Patient has no diabetes, hypertension
PERSONAL HISTORY:
Diet:mixed
Sleep: adequate
GENERAL EXAMINATION: Patient is concious, coherent cooperative and well oriented to time place and person
BP:140/90mm hg
PR:18cpm
RR:96bpm
CVS:S1&S2 heard
RS:wheeze, decreased breath sounds
INVESTIGATIONS:
Treatment:
Inj.lasix40mg iv tid
Inj.monocef 1gmiv tid
Inj.pan 40iv of
Tab Nodosis 500mg po tid
Tab orofer xt po od
Syp ascoryl-ls 10ml po tid
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