A 50 year old male patient with swelling over legs and fever.
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’ve 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.
Case:
HOPI:
- Patient was apparently asymptomatic 1 year back then he noticed swelling over his legs for 10 days ,he went to a local hospital where he was diagnosed with renal failure and he was adviced to get his further treatment in hyderabad .
- He went to a hospital in Hyderabad where he was diagnosed as AKI on CKD and treatment was given for 10 days with 3 dialysis sessions and further medication was given .
- Pedal edema was subsided for the next 6months.after which he presented to our hospital with pedal edema,Diarrhea ,fever and he was diagnosed with AKI on CKD secondary to Acute gastroenteritis ,dialysis was done (3 sessions) after which he failed to followup for further treatment and he presented to our hospital again after 4months with vomitings,fever,pedal edema ,from then he’s on a regular followup and he’s on maintenance hemodialysis.
Now he complaints of fever spike at nights (around 12 am ) and it is associated with chills, headache since 5 days
He also complaints of hiccups since 5 days.
And also complaints of burning sensation in his eyes .
Past history:
He is a known case of DM and HTN since 2 years
Personal history:
Diet:veg,appetite : decreased ,bowel and bladder movements:regular, sleep: adequate
Addictions:
Alcoholic since 30 years daily 180mL
Smoker since 10-15 years (2-3 chutta/day)
Abstinence since 1 year .
General examination:
Patient is conscious, coherent and cooperative and well oreinted to time place and person
He is poorly built and poorly nourished
Pallor : present
Icterus:absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Vitals:
Temp:afebrile(at the time of examination,but patient complained of fever since five days ,which is more during night)
PR : 82bpm ,RR: 17 cycles/min ,BP:130/80 mm of Hg
SYSTEMIC EXAMINATION:
•CVS - S1,S2 heard no murmers
•Respiratory system- vesicular breath sounds heard
•PA- soft,not tender
•CNS- intact
First visit to our hospital :
Patient presented to our hospital (on 27-02-2021 )with chief complaints of :
-pedal edema since 10 days ,
-Diarrhea :watery (4-5 episodes ,not associated with pus or blood)
-associated with high grade fever(since 3 days) .
-h/o involuntary micturtion
Patient was diagnosed as AKI on CKD secondary to acute gastroenteritis.
4 sessions of hemodialysis was done and adviced for further follow-up .
Second visit (10th Aug’,21) and subsequent follow-up:
Patient didn’t followup after his last hemodialysis session in our hospital and he presented to us after about 4 months
With complaints of :
-pedal edema since 4 months
-SOB since 5 days
-H/o vomitings(10episodes),fever since 3 days
-hiccups since 3 days
-decreased urinary output since 3 days
Investigations :
(10th Aug,2021)
HbA1c: 6.6%
Serum creatinine: 9.3 mg/dL
Blood urea: 169 mg/dL
RBS : 175 mg/dL
Hemogram:
CUE:
Serum electrolytes:
Ultrasound report:
HBsAg,HIV,HCV : negative
SARS cov2: negative
RFT:
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