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 plan.
A 75 yr old male who is a resindent of Nalgonda and farmer by occupation came to OPD with
CHIEF COMPLAINTS:
C/o both lower limbs swelling since 7days
Fever since 5days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 20 days back then he had itching of right lower limb followed by swelling of both lower limbs(right >left) - pitting type of edema up to knee.
Fever since 5days which is high grade,intermittent in nature,not associated with chills and rigors,relieved by taking medication.
No H/O decreased urine output,cold,cough,SOB,palpitations,chest pain.
PAST HISTORY:
Had a cataract surgery of left eye 1yr back
Not a known case of DM , HTN , Epilepsy , TB , CVA , CAD
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Diet-mixed
Appetite-normal
Bowel and bladder movements-regular
Sleep-adequate
No addictions
GENERAL EXAMINATION:
Patient is conscious,coherent,cooperative and well oriented to time,place and person.
No signs of pallor,icterus,cyanosis,clubbing,edema,lymphadenopathy
VITALS:
Temp-99.6F
PR-90bpm
RR-19cpm
BP-160/90mmHg
GRBS-105mg/dl
SYSTEMIC EXAMINATION:
CVS examination:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Per Abdominal examination:
Soft , non tender
bowel sounds heard
CNS :
No focal neurological disorder found
Normal speech
PROVISIONAL DIAGNOSIS:
AKI secondary to right lower limb cellulitis
TREATMENT:
1)Inj.Linezolid 600 mg IV/BD
2)Inj.Augmentin 1.2gm IV/TID
3)Inj.PAN 40mg IV/OD
4)T.Chymerol forte PO/TID
5)MGSO4 dressing for right lower limb cellulitis
ECG:
CHEST X-RAY PA VIEW:
30/08/23
Date of admission : 27/08/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Nishitha (PGY2)
Dr.Navya (PGY1)
S
Patient complaints of both lower limbs swelling (right > left)
Fever has been resolved
No complaints of vomitings,loose stools
O
Patient is conscious/coherent/cooperative
Temp:98.4F
Bp: 120/70 mmhg
PR: 84 bpm, regular
RR: 21 cpm
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A: Soft, no organomegaly, bowel sounds heard
A
Right lower limb cellulitis with prerenal AKI
P
1)Inj.Linezolid 600mg IV/BD
2)Inj.Augmentin 1.2mg IV/TID
3)Inj.PAN 40mg IV/OD
4)T.Chymerol forte PO/TID
5)MGSO4 dressing for right lower limb cellulitis
6)2egg whites/day
7)Right lower limb elevation
8)IV fluids NS@50ml/hr
31/08/23
Date of admission : 27/08/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Nishitha (PGY2)
Dr.Navya (PGY1)
S
Patient complaints of both lower limbs swelling (right > left)
O
Patient is conscious/coherent/cooperative
Temp:98.4F
Bp: 110/80 mmhg
PR: 92 bpm, regular
RR: 20 cpm
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A: Soft, no organomegaly, bowel sounds heard
A
Right lower limb cellulitis with prerenal AKI
P
1)Inj.Linezolid 600mg IV/BD
2)Inj.Augmentin 1.2mg IV/TID
3)Inj.PAN 40mg IV/OD
4)T.Chymerol forte PO/TID
5)MGSO4 dressing for right lower limb cellulitis
6)2egg whites/day
7)Right lower limb elevation
8)IV fluids NS@50ml/hr
[28/08/23, 3:20:56 PM] Rakesh Biswas Sir: Which ward?
[29/08/23, 11:48:51 AM] Tejaswini Kandhada: Ward 10 sir
[31/08/23, 4:59:48 PM] Rakesh Biswas Sir: Where is the picture of his limbs with cellulitis?
Share his FBS, PpBs values since admission
[02/09/23, 9:50:15 AM] Tejaswini Kandhada: FBS-83mg/dl
[02/09/23, 9:50:46 AM] Rakesh Biswas Sir: No PpBs since admission?
[02/09/23, 9:51:11 AM] Rakesh Biswas Sir: Share both limbs together always for comparison
[02/09/23, 9:51:20 AM] Tejaswini Kandhada: Ok sir
[02/09/23, 9:51:31 AM] Tejaswini Kandhada: Sir he is not a known case of diabetes
[02/09/23, 9:52:10 AM] Rakesh Biswas Sir: That doesn't matter
To know we need PpBs after every meal
[02/09/23, 9:53:11 AM] Tejaswini Kandhada: Ok sir
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