A 48 year old daily wage labourer came with C/o B/l lower limb swelling,SOB on exertion,Loss of appetite

A Case 48 year old daily wage labourer came with C/o B/l lower limb swelling,SOB  on exertion,Loss of appetite

 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 solve those patient's clinical problems with collective current best evidence based inputs.
This is the case I have been given :-
A 48 year old daily wage labourer came with 
C/o B/l lower limb swelling since 7-10 days 
C/o SOB  on exertion since 1 week 
C/o loss of appetite since 7 days 

Patient was apparently normal 4 months back due to stress(son’s marriage and house dismantled)following which she had generalized weakness and easy fatiguability with occasional headache and neck pains,then she went to RMP and was told that she had hypertension for which she was taking medication(irregularly).Since 1 week patient had B/l lower limb swelling,sob on exertion,loss of appetite.she went to govt hospital and was told to have severe anemia and renal failure when she was discharged after 4 days to our center of hemodialysis.
N/K/C/O DM!ASTHMA,TB,CVA,CAD
Vitals @ Admission :
Temp: 98.6F
BP:130/70 mmHg
HR:80 bpm
RR: 18 cpm
GRBS: 103 mg/dL
SpO2: 98% on RA
General Examination:
Pt is c/c/c
NoPallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS - NAD 
PA - Soft , Tenderness+


Investigations -
Provisional diagnosis-
CRF WITH SEVERE ANEMIA 
Treatment -
1)TAB LASIX 40MG PO/BD
2)TAB OROFER -XT PO/OD
3)TAB NODOSIS 50MG /BD
4)TAB PAN 40MG PO/OD
5)TAB SHELCAL 500MG PO/OD
6)TAB MVT PO/OD
7)INJ EPO 4000U S/C WEEKLY ONCE 
8)SALT AND FLUID RESTRICTION

SOAP NOTES Day 1
DOA:  
S:No fresh compliants 
O:   
BP: 130/70 mmHg
HR:78 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS:  mg/dL

General Examination: 
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs

A:CRF WITH SEVERE ANEMIA 

P:
1)TAB LASIX 40MG PO/BD
2)TAB OROFER -XT PO/OD
3)TAB NODOSIS 50MG /BD
4)TAB PAN 40MG PO/OD
5)TAB SHELCAL 500MG PO/OD
6)TAB MVT PO/OD
7)INJ EPO 4000U S/C WEEKLY ONCE 
8)SALT AND FLUID RESTRICTION



Comments

Post a Comment

Popular posts from this blog

​A 36 Old Male, Cement factory worker by occupation with C/O of Abdominal pain,Right loin pain,Vomitings

Image
A Case of  36 Old Male, Cement factory worker by occupation with C/O of Abdominal pain,Right loin pain,Vomitings 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 solve those patient's clinical problems with collective current best evidence based inputs. This is the case I have been given :- ​A 36 Old Male Cement factory worker by occupation came to the opd with chief complaints of  Abdominal pain since 5days  Right loin pain since 5 days  Vomitings since 5 days  HISTORY OF PRESENTING ILLNESS - Patient was apparently asymptomatic one year ago then he developed pain in abdomen, later he went to the local hospital and was diagnosed to have right renal calculi for which he took treatment and got cured. Then he developed pain in abdomen 5days a
Read more

A 75 year old female patient with shortness of breath ,Bilateral pedal edema

Image
  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 omitt.   Chief
Read more

A 45 year old female with Right tonsillar Hypertrophy with Acute gastritis

Image
A case of 45 year old female with complaints of swelling in B/L Tonsils,Pain and burning sensation in the throat 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 solve those patient's clinical problems with collective current best evidence based inputs. This is the case I have been given :- A 45 year old female who is a power press operator by occupation came with  C/o Swelling of B/L Tonsils since 2 years  C/o Pain and burning sensation in the throat C/o Difficulty in swallowing since 2 years  C/o Back pain since 6 months which is aggregated on doing work  C/o Excessive day time sleepiness since 6 months  Patient was apparently asymptomatic 10 Years back and then she developed B/L tonsil swelling which were touching each other and got cur
Read more