44yr male with CKD,CAD and hypertension
44 yr male with CKD,CAD and hypertension
23/08/2022
Hi, I am P.Durga Bhavani , 3rd Sem Medical Student.This is an 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 patient's 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 the 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 a diagnosis and treatment plan.
CHIEF COMPLAINTS:
A 44 yr old male came was admitted in the hospital on 28/07/2022 with complaints of shortness of breathe,orthopnea, PND(paroxysomal nocturnal dyspnea), and decreased urine output since one month.
HISTORY OF PRESENT ILLNESS :
He was apparently asymptomatic one month ago and developed shortness of breathe grade '4 , orthopnea and decreased urine output.
PAST ILLNESS:
Post CPR status revived
DM since 10 years
Hypertension since 3 years
EXAMINATIONS:
Pallor - yes
No icterus
No cyanosis
Oedema present
No lymphadenopathy
No malnutrition
No dehydration
VITAL SIGNS
GRBS 160 mg %
Heart rate 88bpm
Respiration 14 per minute
BP 110/70 mm of hg
SpO2 98%
Treatment history:
DM present
CAD present
Hypertension present
No asthma
No tuberculosis
No antibiotics
No hormones
No chemoradiation
No blood transfusion
No surgeries
PERSONAL HISTORY:
married
Appetite is normal
Mixed diet
Bowels are regular
Decreased micturition
No known allergies
No addictions
FAMILY HISTORY
no DM
No hypertension
No heart disease
No stroke
No cancer
No tuberculosis
No asthma
No hereditory disease
No psychiatrist illness
No sibling history
SYSTEMIC EXAMINATION
CVS
No thrills
S1 S2 present
No cardiac murmurs
RESPIRATORY
Dyspnea present
Centrally placed trachea
No wheezing
Vesicular breathe sounds
ABDOMEN
scaphoid shaped abdomen
Tenderness is not seen
No palpable mass
Normal hernial orifice
No free fluid
No bruits
Liver is not palpable
Spleen not palpable
Bowel sound are present
CNS
conscious
Normal speech
No neck stiffness seen
No kernings sign
Cranial nerves are normal
Motor system normal
Sensory system normal
Glassgow normal
Reflexes are present
Cerebral signs: no finger nose in-cordination
No knee heal cordination
Normal gait
Other information:
22/08/22
he had fever spike since morning
Vitals
BP 160/90mmhg
Pulse 98 per minute
s1 s2 present
BAE present
Per abdomen soft
CNS = NFND
23/08/2022 He had no fever
