63yr/M Pain Abdomen

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 

Long distance patient- 63yr/M 

* Chief complaints-

   chest pain(burning sensation) 3months 

* Bloating sensation since 1yr 

* incomplete evacuation of stools 3yrs 

Patient was apparently alright 3years ago, then he started experiencing incomplete evacuation of stools 

He passes stools twice a day, normal in consistency

Associated with pain abdomen at night 

Relieves spontaneously 

Pain In the epigastric region and right hypochondric region 

Since 3 years and aggravted on not eating and 

Relievies on eating, drinking water and on taking medication 

Associated with bloating sensation since 1 year and burning type of chest pain(retrosternal) no radiation of pain , no sob, palpitation 

No h/o pain on defecation / straining on passing stools /blood or mucus / constpation altering with diarrhoea 

No h/o malabsorption or weight loss

PAST HISTORY

K/c/o HTN since - 1 year telmisartan 40mg amlodipine 5mg

H/o scabies since 1 year resolved now

PERSONAL HISTORY 

normal apettite and a vegetarian bowel and bladder movements are normal with a h/o 4-5 cigs / day since 20 years 

GENERAL EXAMINATION 

Patient is conscious, coherent, oriented to time place person 

no pallor,cyanosis , icterus ,clubbing,

 with vitals of 

bp:- 140/80mmhg ,

pr:- 82bpm 

grbs:- 98mg/dl

SYSTEMIC EXAMINATION 

Abdomen :- scaphoid , no tenderness present ; bowel sounds heard 

Cvs :- s1s2 heard , no murmurs 

Rs: - bae+ , no added sounds 

Cns :- HMF - intact

Diagnosis - 

INVESTIGATIONS

Hb-12.1

TLC -6,600

Platelet-1.3lakh

Blood urea- 26

Sr. Creatinine 1.1 

Na-141

K-1.3

Cl-106

2Decho- 

No RWMA no AS/MS ; Sclerotic AV

Good LV systolic function 

Diastolic dysfunction; NO PE

71yr Old paraperesis with pyuria

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