57 YR OLD MALE WITH LOWER BACK PAIN AND CHEST PAIN

 I am Soumya 5th semester student .

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CHEIF COMPLAINTS

Since 5 days : 

      Generalized body weakness 
       Pain over upper abdomen 
       Bilateral pedal edema 
       Burning sensation of both soles
- SOB at rest since 3 days


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 5 days ago he developed generalised body pain which is aggravated on exertion and relieved on medication.
- He also experienced burning pain over epigastric region which is also aggravated on exertion and relieved on medication.
- Fever was also present with chills and rigors.
- Bilateral pedal edema was developed which aggravated on walking and relieved on rest.
- Burning sensation of both soles which is present through out the day and SOB at rest.
- Nausea and giddiness since yesterday.

HISTORY OF PAST ILLNESS

K/c/o Chronic kidney disease
( Use of NSAID'S for 1 year due to pain near 1st metatarsal joint and foot )

Diabetes - No

Hypertension - No

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - Nil


FAMILY HISTORY

not significant

PERSONAL HISTORY

Diet -  Mixed

Appetite - lost since 10-15 days

Bowel and bladder - Regular movements 

Allergies - No

Addictions - Chewing tobacco

- 90 ml of whiskey occasionally (Once in a month) but stopped 4 months ago 


GENERAL EXAMINATION













  • O/E
  • Pallor: present 
  • Icterus: absent
  • Cyanosis: absent
  • Clubbing of fingers: absent
  • Lymphadenopathy: absent
  • Oedema of feet: present pitting type
      Vitals:
  • PR : 96 bpm
  • Temp : 102  F 
  • RR : 34 cpm
  • BP : 180/90 mmHg

SYSTEMIC EXAMINATION
 CVS: 
    Thrills: no
    Cardiac sounds:S1 ,S2 present 
    Murmurs : absent 
 RS:
    Dyspnea and Wheeze are present
    Position of trachea: central
    Breath sounds: vesicular 
 Abdomen


    Shape of abdomen: scaphoid 
    Tenderness: No
    Palpable mass: no   
    Bowel sounds :Present 


 CNS :
  •    normal  
  •  Patient is Consious, Coherent, Well oriented to time place and surroundings

PROVISINAL DIAGNOSIS


CHRONIC RENAL FAILURE 


  
 INVESTIGATIONS











27/8

                     










30/8



HIV 1/2 Rapid - Non reactive
HBsAG Rapid - Non Reactive
Anti HCV Antibodies Rapid - Negative
Blood group - B Neg





31/8




1/9










30-08-2022

Diagnosis : CHRONIC RENAL FAILURE 

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


31-08-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever and chest pain

On examination : 

Patient is C/C/C

BP : 120/60 mm of Hg

PR : 82bpm

CVS : S1, S2 present

 RR : 22 cpm

RS : BAE +

P/A soft 

CNS : NAD

Temperature : 101°F

GRBS : 97 mg/dl

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


01-09-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever , left side chest pain and left knee , ankle pain.

On examination : 

Patient is C/C/C

BP : 110/60 mm of Hg

PR : 76bpm

CVS : S1, S2 present

 RR : 24 cpm

RS : BAE +

P/A soft  and non tender

CNS : NAD

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


Popular posts from this blog

29 year old with bilateral lower limb pain

Image
  I am Soumya 9th semester student . This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them CASE SCENARIO 29 yr man from Miryalaguda ,a agriculture coordinator K/C/O CKD came to casualty with cheif complaints of Bilateral lower limb pain since 20 days HISTORY OF PRESENT ILLNESS Patient was apparently normal 3 years ago then developed pain in right lower abdomen diagnosed to have renal stones of size 4mm to 6mm and also raised creatinine upto 6 for which he had medication and both problem of stones and creatinine came down Then after 6 months he had bilateral ankle pain ,which is pricking type and precipitated by heavy work for which we visited a local doctor where he found rised uric acid levels , also adviced decrease protien rich diet along with medication  also had hist
Read more

18 Y FEMALE WITH WEAKNESS IN LOWER LIMBS

Image
Soumya Menda 3rd sem This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.  Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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 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. Case scenario: A 18 year old female came to causality on 8/7/21 with Cheif complaints of Weakness in both lowerlimbs.  Unable to stand and walk.   History of present illness: 18 year ol
Read more

OSCE questions

Image
https://soumyamenda80.blogspot.com/2023/11/29-year-old-with-bilateral-lower-limb.html 1.How NSAID abuse effects on kidney leading to renal injury and How long exposure and dosage can cause injury The main mechanism of NSAID action is cyclooxygenase (COX) enzyme inhibition, interfering on arachidonic acid conversion into E2 prostaglandins E2, prostacyclins and thromboxanes. Within the kidneys, prostaglandins act as vasodilators, increasing renal perfusion. This vasodilatation is a counter regulation of mechanisms, such as the renin-angiotensin-aldosterone system works and that of the sympathetic nervous system, culminating with compensation to ensure adequate flow to the organ. NSAIDs inhibit this mechanism and can lead to acute kidney injury (AKI). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534025/ 2.What other drugs or treatment modalities could be possible other than NSAIDs for pain? He had history of Rat poison ,does it have any significance in etiopathogenesis of the
Read more