A 60 yr old male patient with loss of appetite

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 plan.


A 62 year old male patient came to OPD for Dialysis.

History of presenting illness:

Patient was apparently  asymptomatic  one month back then he developed shortness of breath and loss of appetite.SOB is sudden in onset gradually progressive.After 20 days he had complaint of shortness of breath, fever and loss of appetite for which he went to private hospital  where he was told to have raised serum creatinine then he came to our hospital for dialysis.Fever was treated  outside in private hospital 5 days back.Vomitings since 2 days, 2-3 episodes per day, food and water as content ,non projectile.

 Past history:

He has history of fall 5 years ago and knee surgery was done and diagnosed with HTN and DM type 2 and he is on irregular medication.No history of asthma, tuberculosis, Thyroid disorders.

Personal history:

Diet :mixed

Appetite :decreased since 30 days

Sleep :adequate

B&B: regular

Addicitons:Beedi smoker from 2-3 years

General Examination:

He is concious coherent cooperative.

Pallor is present,icterus clubbing cyanosis lymphadenopathy pedal edema absent

Temperature- afebrile

Blood pressure 110/80

Pulse rate- 78 bpm

Respiratory rate- 15 cpm 

Systemic Examination



On inspection

Shape of chest :bilaterally symmetrical.

Movement of chest wall : symmetrical.

Palpation

Position of trachea :central

Symmetrical chest expansion

Percussion:

Resonance is heard bilaterally

Auscultation:

Normal vesicular breath sounds are heard

No wheeze

Abdomen:

Shape:scaphoid

No scars swellings are seen

On palpation:

Non tender, soft, liver spleen not palpable

On auscultation:

Bowel sounds heard


Investigations:






HRCT done on 12-02-2022






Comments

Post a Comment

Popular posts from this blog

Stroke

Image
70 year old male farmer by occipation, Resident of Nalgonda came to hospital with chief complaints of inability to lift left upper and lower limb since morning. HOPI: Patient was apparently asymptomatic 20 days back then he developed generalized weakness. On 24 August 2022: After his dinner at 8 PM,he went to bed 9 PM. On 25 August 2022 Morning when he was about to wake up from the bed,he could not lift his left Upper and Lower limb which was Sudden in onset and there is loss of speech since morning then he was immediately Hospitalised. There is no H/o fever,head injury,Vomiting Loss of consciousness, palpitation,chest pain. H/o bilateral pedal edema 7 month back for which he went local hospital then he diagnosed with Right mild hydroureteroephrosis,Gall bladder slugde with calculi,Fatty Liver. PAST HISTORY: No similar complaints in past. He is known case of diabetes and Hypertension since one year and was on  regular medication.  No H/o Tuberculosis, Epilepsy,Asthma. PERSONAL HISTORY:
Read more

1801006082 L

Image
  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 Chief complaints: 75 years old male came to OPD with cc of pedal edema since 1month,shortness of breath since 20days,vomitings since 10days  History of present illeness: patient was apparently asymptomatic 1month back Than he developed bilateral pedal edema which is insidious in onset gradual in progression upto the knee and pitting type edema no aggrevating and no relieving factors . Patient also complains of shortness of breath since 20days which is sudden in onset gradual in progression ,aggrevating on doing work, walking and temporarily relived on medication and also he had history of vomitings which is su
Read more

1801006082. S

Image
    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 plan. A 38 year old male , civil engineer by profession and resident of West Bengal came to  OPD with chief complaints of :  Abdominal pain since 5years     HISTORY OF PRESENTING ILLNESS: Patient was apparently a
Read more