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 a
solve those patient's clinical
problems with collective current
evidence based inputs.
This E log also represents
my patient Centered online Learning
portfolio and valuable inputs on
Comment box is welcome.
Bhavana Chenna,
9th Semester,
Roll No - 20.
Case Discussion:
I have been given this case to solve in an order to 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.
A 67 Year old Male , Weaver by Occupation Came to the Hospital on 22nd March with the :
Chief Complaints :
* Decreased Urine Output since 15 days
* Burning Micturition since 15 days
* Lethargy since 15 days
History of Present Illness :
Patient was Apparently Asymptomatic one year back then he Developed :-
* Patient had decreased urine output and whenever he tried to micturate, it was associated with burning sensation in the penis, which lasted for 20mins.
* Because of this symptom (dysuria), he totally decreased intake of fluids so that he won't get painful urination. Whenever he passes urine, it totally amounts to 10ml.
* Patient had complaints of poor stream of urine and urinary incontinence since 1 year.
* Because of his urinary incontinence, patient totally avoided social gatherings in the past 1 year.
* He was experiencing episodes of nocturia in this one year associated with altered sleep cycle.
* He had two episodes of vomiting, non-bilious, non-projectile, containing food particles since 15 days. He had 4-5 episodes of loose tools per day.
* Burning sensation in the tongue and throat so that he was taking only minimal water and milk.
* 10 days back, he experienced dysphagia for which he was hospitalised and was Managed for the same.
* History of fever on and off
* No history of Dyspnoea, Shortness of Breath, Palpitations, Chest pain and Paroxysmal Nocturnal Dysuria.
* No history of Abdominal pain, Abdominal Distension.
* History of burning micturition and Pyuria.
History of Past Illness :
* Not a known case of Hypertension, Diabetes Mellitus, Hypothyroidism, Stroke and Epilepsy.
* H/O cataract surgery 2 months back.
Personal History :
* Diet - Mixed diet
* Appetite - Decreased
* Sleep - Inadequate
* Bowel and Bladder Movements - Regular
* Addictions - Alcoholic since 20 years takes quarter daily stopped 10 days back.
Family History :
* Not significant
Physical Examination :
General Examination :
Patient is Conscious, Coherent and Cooperative
He is well oriented to Time, Place amd Person.
He is Mildly Nourished.
* Pallor - present
* Icterus - Absent
* Clubbing - Absent
* Cyanosis - absent
* Edema - absent
* Lymphadenopathy - absent
Vitals :
* Temperature - Afebrile
* Blood Pressure - 100/70 mm Hg
* Pulse Rate - 96 BPM
* Respiratory rate - 20 CPM
* Spo2 - 97%
* GRBS - 79 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM :
* S1 and S2 are Heard.
* No Murmurs are Heard.
RESPIRATORY SYSTEM :
* Bilateral Air Entry Present.
* Position of Trachea - Central.
Central Nervous System :
* Patient is Conscious.
* Higher mental functions are normal.
* No abnormality detected.
Per Abdomen :
* Abdomen is Soft and Non Tender and Not distended.
* No Organomegaly.
* No Palpable mass or Fluid Present.
Investigations :
Ultrasound done on 20/12/2019 -
Ultrasound done on 18/10/2021 -
Done on 22/03/2022 -
Done on 24/03/2022 -
* Blood urea- 136
* Serum Creatinine- 6.2
Abg:
* PH- 7.2
* PCO2- 8.8mmHg
* SpO2- 96.1%
* HCO3- 3.5mmol/L
Provisional Diagnosis :
* Recurrent Urinary Tract Infection secondary
to ? Renal calculi
* Acute Kidney Injury on Chronic Kidney
Disease.
* Normocytic Normochromic Anaemia.
Treatment :
1. IVF NS & RL @100ml/hr
2. Injection. Monocef 1Gm/PO/ND
3. Injection. Pan 40 mg/IV/OF
4. Mucopain gel ointment for L/A
5. GRBS 6th hourly
6. Vitals monitoring 4th hourly
