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 60 year old female came to the opd with the chief complaints of pedal edema since 3 years, burning micturition,cough since 15 days,facial puffiness and breathless since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 20days ago then she had high grade fever and chills,rigor since 3days.Fever was intermittent and relieved on medication and cough was non foul smelling and productive.
Since 1day patient had facial puffiness and breathless for which he went to a hospital.
HISTORY OF PAST ILLNESS:
Patient had knee joint pain 4years and low back pain since 3years for which she had taken nsaids and ointments, pateint also had pedal edema upto knee.
PERSONAL HISTORY:
Agriculture but stopped it since 2yrs
Appetite: lost since 2months
Diet: mixed
Bowel and bladder movements: regular
Micturition: abnormal
Allergies:no
Habits:betel chewing since 40yrs
FAMILY HISTORY:
No relevant family history
GENERAL EXAMINATION:
Patient was concious cooperative coherent and well oriented to time place and person.
No pallor,no cyanosis no icterus no clubbing VITALS:
Temperature: afebrile
Pulse rate:78bpm
Respiratory rate:18cpm
Bp:110/80mm/hg
SYSTEMIC EXAMINATION:
CVS:
S1, S2 heard,no murmor
RESPIRATORY:
No wheeze,trachea cental in position,breath sounds are vesicular
ABDOMEN:
Shape:obese
No tenderness,no palpable masses,no hernial orrifices,no free fliud,no bruit,liver and spleen not palpable
CNS:
Concious
Speech:normal
Gait:normal
No neck stiffness
Sensory,motor systems are normal
PROVISIONAL DIAGNOSIS:
AKI secondary to sepsis
INVESTIGATIONS:
TREATMENT:
INJ.Pantop:40mg/iv/od
Inj zofer 4mg ivInj.neomol 1gr/ivInj.Moxicef 1gr/iv/bd
Tab Nodosis bo/bd
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