General medicine elog

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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.

A 29 year male came to opd with chief complaints of 

Bilateral pain in lower limbs upto knee since 20 days

HOPI

Patient was apparently asymptomatic 3 years ago then developed severe sudden pain in right lower abdomen for which he went to local hospital and was diagnosed to have renal calculus of 4 - 6 mm and got treated for it

6 months later patient developed pain in lower limbs bilaterally for which he visited a local doctor and was tested with high uric acid levels for which he got treated

followed by this he was intermittently having lower limb pain for which he was having acyclophenac whenever he was having episodes of pain

Since 20 days pain wasn't reliving on medication and he got admitted to a local hospital. his creatinine levels were 8.2 for which he was referred to our hospital

Past history

 3 years ago he had lower abdomen pain diagnosed renal stones of 4 mm size - relieved on medication,

Not a known case of diabetes , hypertension ,asthma ,tb,cardiovascular , diseases.

Personal history

Diet : mixed

Appetite normal 

Sleep : inadequate due to pain since 20days 

Bowel and bladder movements regular

No allergies

Occasional alcohol consumption 

Chronic smoker since 6 years ( stopped 8 months back) 

TREATMENT HISTORY 

H/o usage of NSAIDs for pain since 2 yrs 

FAMILY HISTORY 

Not significant 

General examination 

Patient was conscious coherent and cooperative 

Moderately built , moderately nourished

Pallor present 

No  icterus ,cyanosis, clubbing lymadenopathy,edema.










Vitals 

BP -140/80

RR - 14/min

Temp - 98F 

Pulse rate - 78bpm 

Spo2 98percent 

Grbs - 134 mg%

SYSTEMIC EXAMINATION  

Respiratory examination

Dyspnoea: No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid , inverted umbilicus, no engorged veins, no scars

No tenderness, no palpable mass, No Fluid

No bruits heard

Liver not palpable

Spleen not palpable or any 

CNS Examination

Conscious coherent cooperative

Higher mental functions intact

No signs of meningitis 

Cranial nerves, motor system, sensory system Normal. 

Investigations














INVESTIGATION 

HIV - non reactive 

HBsAg - negative 

RBS - 114 mg/dl

Blood urea - 176 mg/dl 

Serum creatinine - 7.8mg/dl

PROVISIONAL DIAGNOSIS 

CHRONIC KIDNEY DISEASE secondary to NSAID abuse 

TREATMENT 

 1) salt restriction <2 g /day 

 2) fluid restriction <1.5L /day 

 3) T.NODOSIS 500mg PO/BD 

 4) T.OROFER-XT PO/OD

 5) T.SHELCAL - CT PO/OD 

 6) T.CAP BIO D3 60,000IU units per weekly 

 7) T.LASIX 10 mg PO/BD 

7) moniter vitals 4 th hrly

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