57 YEAR OLD MALE
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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.
Following is the view of my case:
Chief complaints:
Pain in both knees since 30 days
Swelling of both lower limbs and right hand since 1 week
Difficulty in walking since 1 week
Fever since 1 week
HOPI:
Patient was apparently asymptomatic 30 days back then he developed pain in both knees for
Which he came to our hospital where he was prescribed hifenac p for pain relief ,after which pain was decreased.
Then after few days patient developed bilateral pedal oedema extending up to knee which was of pitting type. Then the patient was unable to walk.
He also developed fever since 1 week which was of low grade and intermittent in night time. Fever was not associated with chills and rigours
No H/o vomiting, loose stools and blood in stools No H/o decreased urine output ,burning micturition ,frothy urine, haematuria
No H/o chest pain ,palpitations and dyspnoea
PAST HISTORY:
Not a known case of DM, HTN, ASTHMA, EPILEPSY,CAD,CVA.
FAMILY HISTORY:
No significant family history
General examination:
Patient is conscious, coherent, cooperative
Well oriented to time, place and person
No pallor
No cyanosis
No clubbing
No lymphadenopathy
Oedema of both foot and right hand present
Vitals:
Temperature: afebrile
BP:130/80mmHg
PR:100bpm
RR:18cpm
SpO2:97% on RA
Systemic examination
Cvs:
S1 S2 present
No thrills
No murmurs
Respiratory system:
Vesicular breath sounds
Position of trachea is central
No dyspnoea
No wheeze
Abdomen:
Is scaphoid
No tenderness
No palpable masses
No free fluids
No bruits
Liver and spleen are not plapable
Bowel sounds present
CNS:
Patient is conscious
Normal speech
No neck stiffness
Glasgow scale 15/15
Reflexes -normal
Investigations:
14/12/2022
Hemogram
Hb: 10.4
Total count:9100
Neutrophils:75
Lymphocytes:15
Eosinophils:2
Pcv: 32.1
Mcv:63.6
Mch:20.5
Vitals:
Temperature: afebrile
BP:130/80mmHg
PR:100bpm
RR:18cpm
SpO2:97% on RA
Complete urine examination:
Colour : pale yellow
Appearance: clear
Reaction: acidic
Sp gravity:1.010
Albumin: nil
Sugar : nil
Bile salts: nil
Bile pigments: nil
Pus cells:2-3
Red blood cells: nil
Crystals: nil
Casts: nil
LFT
Total bilirubin: 1.89
Direct bilirubin:0.96
SGOT:44
SGPT:37
ALP: 298
Total proteins:5.5
Albumin:2.87
A/G ratio: 1.09
C reactive protein: negative
Rheumatoid factor: negative
Blood group: B POSITIVE
ESR:25mm/1st hour
Serum electrolytes:
Sodium:130
Potassium:4.2
Chloride: 103
Calcium ionized:0.96
Urinary chloride: 106
urine sodium:62
urine potassium:5.4
urine chloride:106
Urine protein/ creatinine ratio:0.19
Phosphorus:2.5
Blood urea :30
Serum creatinine:0.7
Serum osmolality:227.7
Complete urine examination:
Colour : pale yellow
Appearance: clear
Reaction: acidic
Sp gravity:1.010
Albumin: nil
Sugar : nil
Bile salts: nil
Bile pigments: nil
Pus cells:2-3
Red blood cells: nil
Crystals: nil
Casts: nil
LFT
Total bilirubin: 1.89
Direct bilirubin:0.96
SGOT:44
SGPT:37
ALP: 298
Total proteins:5.5
Albumin:2.87
A/G ratio: 1.09
C reactive protein: negative
Rheumatoid factor: negative
2D echo:
TAB ALDACTONE 50 MG PO OD
INJ PAN 40MG IV OD
INJ NEOMOL 1GM IV SOS
TAB DOLO 650 MG PO TID
GRBS 6th hourly Monitoring
Vitals Charting 4th hourly
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