A 55yr old male c/o sob since 2days

 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 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

Cheif complaints:

A 55yr old male patient came to casuality with c/o 

Sob since 2days

Lower back pain since 2days 

C/o burning sensation in stomach after eating spicy food since 2 months

Cough since 1day

Hopi:

Patient was apparently asymptomatic till 2months back ,then he developed burning sensation in stomach after eating spicy food, associated with decreased appetite and loss of weight.

Shortness of breath since 2 days ,grade 2 ,no orthopnea,no pnd.

Lower back pain since 2days , dragging type of pain,non radiating.

C/o cough since 1 day , productive cough.

No h/o fever ,cold

Personal history:- 

Diet- mixed 

Appetite -narmal

Bowel and bladder movement-regular

Sleep -adequate 

Addictions- no

General examination:- 



Patient is conscious, coherent,cooperative

Moderately built,moderately nourished 

No Pallor,icterus, cyanosis, clubbing,lymphadenopathy,bilateral pedal edema  


Vitals:- 

BP- 110/80mmhg

PR -85bpm

RR-20cpm

Spo2 99% at room air 

GRBS - 107mg/dl

Temperature -99.4


Systemic examination:-

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE,no added sounds ,NVBS, 

P/A: soft, distended, mild tenderness in epigastric region 

CNS: higher mental functions intact, no focal neurological deficit 


Provisional Diagnosis-

Acute kidney injury on chronic kidney disease with acute gastritis 

Investigations:


















GASTROENTEROLOGY REFFERAL:


UPPER GI ENDOSCOPY





Treatment:

Inj PAN 40MG IV STAT

INJ SODIUM BICARBONATE 25MEQ IV STAT

TAB LASIX 20MG PO BD

TAB NODOSIS 500MG PO BD

TAB SHELCAL 500MG PO OD

TAB OROFER XT PO OD 



Advice at discharge:

TAB KINPRIDE PO TID

TAB RAZO 20MG PO OD BBF

TAB NODOSIS 500MG PO BD

TAB SHELCAL 500MG PO OD

TAB OROFER XT PO OD 

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