56 YEAR OLD MALE WITH C/O S.O.B





FINAL EXAM SHORT CASE :

Chief complaints:
A 56 yr old male patient resident of Aganmothkur,who is a farmer ,came to the hospital with chief complaints of shortness of breath since 1 day.

History of presenting illness:
   Patient was asymptomatic 3 months back.Then he developed bilateral pedal edema of grade-4 pitting type and shortness of breath grade-3 for which he was hospitalised and was diagnosed to have Chronic kidney disease .
  Since then he had 11 sessions of hemodialysis .The last one was done as he had shortness of breath of grade-3 and bilateral pedal odema grade -3 pitting type .



Past history:He went to hospital as he had fever and diagnosed to have Hypertension 5 months back .

Underwent surgery for hollow viscous perforation 2 yrs ago.



GENERAL EXAMINATION: The patient is conscious, coherent, coperative .Moderately built and nourished.

•Pallor present


•Bilateral pedal odema -pitting type-grade 3





No cyanosis, No clubbing, No koilonychia,No lymphadenopathy.

Incisional hernia above the umbilicus





Hemodialysis:CVP line


Drugs:

Tab.lasix 40mg bd

Tab.nicardia 10mg tid

Tab.shelcal od

 


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This is an 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.    A 41 year old male admitted to pyschiatry ( de-addiction centre)  As he has h/o alcohol consumption since 10 years, Tobacco chewing since 10 years. HOPI: patient consumes intially 90ml of whiskey with his
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