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 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-centred 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
CHIEF COMPLAINTS:
Shortness of breath since 1 days
Decreased urine output since 3days , anuria since morning
Facial puffiness since 3 days
B/l pedal edema since 1 week
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 week ago the developed bilateral pedal edema insidious in onset , progressive in nature, pitting type , extending upto knee joint. Decreased urine output since 3 days less than 500 ml /day , and anuria since morning. Facial puffiness since 3 days. Shortness of breath since 1 day, sudden onset, orthopnea present . No PND, chest pain , palpitations and giddiness . No history of fever , cough, vomiting loose stools , burning micturition. K/c/o seizure disorder since 18 years , H/o seizure episode once monthly and fall after episode, even on medication with sodium valproate 300 mg PO /OD.
PAST HISTORY:
K/C/O seizure disorder on Tab. Sodium valproate 300 mg PO/BD
Not a K/c/o HTN/ DM/ CKD/ /TB
PERSONAL HISTORY:
Appetite-Decreased
Diet - Mixed
Bowel and bladder - regular
Sleep - Decreased.
General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Pedal edema - pitting type extending till knee
VITALS : Temp - 98.6 F
PR - 92bpm
BP - 160/60 mmhg
RR - 36 cpm
SPO2 - 84% onRA
96% on 6lit of O2
GRBS - 102 mg/dl
Systemic examination:
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
JVP raised
No visible pulsations, scars , sinuses , engorged veins.
Palpitation:
Diffuse Apex beat present
Parasternal heave present
Epigastric pulsations present
Palpable A2P2
Auscultation :
S1 and S2 heard.
PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration
No scars , sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpitation :
Abdomen is soft and tenderness present in right hypochondrium
No organomegaly.
Percussion :
Tympanic note heard over the abdomen.
Auscultation:
Bowel sounds are heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
Bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps ++ ++
Supinator + +
Knee ++ ++
Ankle. + +
Diagnosis: Heart failure with cardiogenic pulmonary edema with bilateral pleural effusion.
Hypervolemic hyponatremia secondary to heart failure
K/c/o seizure disorder
Anaemia ( ? Iron deficiency anaemia)
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