This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
Case
A 37 year old male came to the casualty with the chief complaints of shortness of breath since 6 days and generalised swelling of the body.
History of present illness
The patient was apparently asymptomatic 12 years back then he developed generalized swelling all over the body which was insidious in onset and gradually progressed up to 3 months and then he came to our hospital and he was referred to the higher Centre afterwards. When he was in our hospital ,when the BP was checked there was so much variation found between the two arms. In the higher Centre ,he was treated for about a 4 to 5 days and then he became normal and got discharged . For 3 months he didn't take any alcohol or any smoking but after 3 months he again started drinking alcohol and smoking.
Afterwards he had on and off episodes of edema,so he was took a tablet of lasilactone and the edema subsided after taking the tablet. 2 months back he developed edema which did not subside on medication, so he came to our hospital and was given lasix. 5 to 6 days back,he again started developing edema which didn't subside even after taking a higher dose of the tablet and he developed a shortness of breath from the past 4 days. He is not taking enough meals because he is having that SOB and distension of abdomen while sitting and eating. He had a good appetite but he was not able to eat. On September 14th around morning from 1:00 a.m. he had shortness of breath and around 3:00 a.m. he was not able to take breath and came to our hospital
H/o dark colored stool since 4 day
H/o decreased urine output since 3 days
H/o dry cough ( sometimes only )
No h/o of fever ,
He is a chronic alcoholic since 2002
He takes alcohol almost daily about a 15 units.
Last consumption of alcohol was 20 days back.
A chronic smoker takes 1 - 2 packs per day
Past history
Personal history
Diet -mixed
Appetite-normal
Sleep - disturbed(unable to sleep in the night and slept in the mornings)
Bowel- dark coloured stools since 4 days
Bladder- decreased frequency and quantity
Addiction-
Chronic alcoholic since 16 years and nearly for 8 years he consumed daily around 15 units of alcohol
Chronic smoker: 1-2 packs per day.
Family history
General physical examination
Pallor: absent
Icterus: yellowish discoloration of sclera-present
Cyanosis-absent
Clubbing-present
Lymphadenopathy:absent
Edema- generalised edema is present
Systemic examination
Systemic examination:
CVS:
Inspection:
Pericordial pulsations visible (vaguely)
Palpation:
Apex beat felt in 6th intercostal space, 10cm from sternum
Parasternal haeves,thrills are felt.
Percussion:
Auscultation:
GIT:
?Abdomen distension,soft and non tender
?shifting dullness
?Hepatomegaly
Respiratory:
CNS: No focal neurological deficits present
Investigations
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