January 5th, 2023
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 diagnosis and treatment plan
Dr. Lohith Varma
PGY1 - GM
75yr old male retired survey officer, came with chief complaints of
•Turbid urine since 15days
•Pedal oedema since 10days
•Swelling of upper limbs and Facial puffiness since 3days
•Fever with chills and back pain since 3days
Patient Was Apparently Asymptomatic 15days ago when he started noticing passage turbid urine with burning sensation, decrease in urine output present
no h/o fever or discomfort while urinating or blood in urine or Pain Abdomen
He started having bilateral pedal oedema which was insidious in onset and gradually progressive in nature up to the knees, painless, aggravated during the day and relieved at night associated with dyspnea on walking present, no h/o orthopnea, PND, palpitations, oliguria, alcohol intake or yellowish discolouration of eyes and urine
Associated with swelling of upper limbs and facial puffiness since 3days
And low grade fever, intermittent type, insidious in onset and gradually progressive in nature with chills and lower back pain
He is a known case of asthma since 50years and uses salbutamol inhaler
He was admitted in hospital for 40days, 8months ago, after which he was unable to walk on his own, he is walking using a walker
He was having On and off pedal edema since last 1 year
Not a known case of DM,HTN,Tb,CVA,CAD or epilepsy
Personal History
Appetite- decreased
Diet- vegetarian
Bowel and bladder- regular
Sleep- adequate
Addictions- nil
Family history- insignificant
General examination
Patient is conscious , coherent and cooperative
Facial puffiness and swelling on upper and lower limbs seen
Vitals-
BP-126/80mmhg
RR-24cpm
PR-78bpm
SpO2- 100% on RA
Temp- 99.8F
GRBS-122gm/dl
CNS-
Right. Left
iliospoas (flexion). 4- 4-
(Extension). 4+. 4-
Adductor femoris 4- 4-
Gluteus medius 4- 4-
& Minimus
Gluteus maximus 4- 4-
Hamstrings 4- 3
Quadriceps 4- 4-
Plantar flexion 4+. 4+
Dorsal flexion 4- 4-
Eversion of foot 4+. 4+
Inversion of foot 4- 4-
TEST. Right. Left
I – SPINOTHALAMIC
1. Crude touch. Present. Present
2. Pain. Present. Present
3. Temperature. Present. Present
II – POSTERIOR COLUMN
1. Fine touch. Present. Present
2. Vibration.
3. Position sense. Present. Present
III – CORTICAL
1. Tactile localisation. Present. Present
2. Graphaesthesia. Present. Present
3. Stereognosis. Present. Present
1.Iatrogenic fishing’s syndrome secondary to chronic steroid inhalers with bronchial asthma since 50years
2. hyponatremia and hypokalemia (Resolving)(Secondary to Cushing’s syndrome)
3.Mild Lumbar Spondylitis, coccyx fracture
4.with cystitis with umbilical hernia
5.UTI(resolving) with grade I prostatomegaly
1. Inj Piptaz 4.5gm/Iv/TID
2. Inj. Pan 40mg IV/OD
3. Inj. Noemal 1gm/IV/SOS
4. IVFluids 1 point NS @75ml/hr
5. Tab. Dolo 650mg PO TID
6. Syp. Potchlor 15ml/PO/TID
7. Inj. Zofer 4mg/IV/OD
8. 2-3scoops of protein powder in 120ml milk
9. Nebulisation with Buddcort and Ipratropium 12hourly
10. Plenty of egg whites
11. Inj. KCL 20meq in 100ml NS/ slow IV
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