44Y OLD MALE ABDOMINAL DISTENSION AND COUGH
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 44 YROLD MALE CAME TO OPD WITH
COMPLAINTS OF B/L PEDAL OEDEMA SINCE 6 MONTHS,
ABDOMINAL DISTENSUIN SINCE 6 MONTHS COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS AGO THEN HE DEVELOPED B/L PEDAL EDEMA PITTING TYPE INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE NO AGGREVATING AND RELIEVING FACTORS
ABDOMINAL DISTENSION SINCE 6 MONTHS INSCIDIOUS ONSET GRADUALLY PROGRESSIVE INITIALLY SMALL IN SIZE PROGRRESSED TO PRESENT SIZE
PT INITIALLY WENT TO OUT SIDE HOSPITAL DIAGNOSTIC TAP WAS DONE ( NO DOCUMENTS AVALIBLE ) THEN DISCHARGED WITH MEDICATION (LASIX)
COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS NO AGGREVATIMG AND RELIEVING FACTORS
NO H/O CONSTIPATION,BURNING MICTIRITION,NAUSEA, VOMITING
NO H/O FEVER,COUGH, BREATHLESSNESS, LOOSEMOTIONS, CHEST PAIN, PALPITATIONS,ORTHOPNEA,PND
NO H/O DM, HTN, ASTHMA, TB, EPILEPSY
,CVA,CAD,CKD
PERSONAL HISTORY OCCUPATION AUTO DRIVER
ALCOHOL INTAKE DAILY SINCE 20 YRS 1LT PER DAY
CIGERETTE SMOKING
EXAMINATION
PT IS C/C/C
NO PALLOR,ICTERUS, CYANOSIS,CLUBBING, LYMPHADENOPATHY,OEDEMA IN FEET
TEMP AFEBRILR
PR 86BPM
RR 18CPM
BP 110/80 MMHGABDOMINAL EXAMINATION
SHAPE DISTENDED
NON TENDER
NO PALPABLE MASS
HERNIAL ORIFICES FULL
FREE FLUID PRESENT
NO BRUITS
FLUID RESTRICTION LESS THAN 1.5 LIT/DAY
SALT RESTRICTION <2 GM / DAY
2 TO 4 EGG WHITES /DAY
TAB LASILACTION 10/50MG PO OD 1 WEEK
TAB LASIX 40 MG PO OD 10 DAYS
TAB THIAMINE 100 MG PO BD 1O DAYS
SYP LACTULOSE 25ML PO HS 10DAYS
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