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Name: G Sai Manogna
Roll no: 33
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 :
CASE PRESENTATION:
A 60 year old male patient who is a resident of Nalgonda has come to the OPD with the chief complaints of
- Burning micturition since 10 days
- Dry cough since 5-6 days
- High grade fever since 4-5 days
- Constipation since 4-5 days
- SOB on exertion since 4 days
History of Presenting illness:Patient was apparently asymptomatic 10 days ago then developed burning micturition which was sudden in onset, gradually increasing in intensity
Dry cough was developed 5-6 days ago and was relieved on taking medication
High grade fever was developed 4-5 days ago which is continuous, associated with chills and rigors.
There were no aggrevating factors and was relieved by taking medication
Constipation was developed 4 days ago
Shortness of breath since 4 days
Past history:
Similar history 1 year ago
Patient is a known case of Hypertension and diabetes since 30 yrs and is on medication
Not a known case of TB, Asthma, Epilepsy
No history of blood transfusions
No history of any previous surgeries
Personal history:
Diet- Mixed
Appetite- Good
Sleep- Adequate
Bowel- Regular
Micturition- Burning micturition
Addictions- Occasional alcoholic
Allergic history:
No history of known allergies
Family history:
No significant family history
No family history of Hypertension, Diabetes, TB, Asthma
General Physical Examination:
Patient is conscious, coherent, cooperative
well oriented to time, place and person
well nourished and moderately built
Pallor- Present
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Present
Vitals:
Temperature- Febrile (101degree F)
Pulse rate- 80bpm
Respiratory rate- 18cpm
Blood pressure- 120/70 mm/Hg
SPO2 - 98%
Systemic Examination:
Cardiovascular System:
S1 and S2 sounds are heard
No abnormal murmers
Respiratory System:
Bilateral air entry present
Trachea is central
Normal vesicular breath sounds are heard
No adventitious sounds are heard
Abdominal Examination:
Shape of abdomen is distended
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly
Central Nervous System:
No focal neurological deficits
Investigations:
CBP:
Hb- 10.7
TLC- 11400
Platelet- 1.2 L
RFT:
Urea- 140
Creatinine- 4
Serum electrolytes:
Sodium- 136
Potassium- 2.9
Chloride- 95
RBS- 297
Liver Function Tests:
AST- 28
ALT- 31
ALP- 241
T.P- 6.2
Albumin- 2.1
Complete Urine Examination:
Slightly cloudy
Albumin- +
Pus cells- 3 to 4
Epithelial cells- 1 to 2
RBCs - 1 to 2
Temperature Chart:
ECG:
USG:
Provisional Diagnosis:
Chronic cystitis
?UTI
?AKI on CKD
Treatment:
- Intravenous NS and RL
- Inj. Monocef
- Inj. Pantop
- TAB. Dolo
- Inj. Neomol 1gm (IV)
- I/O charting strictly
- Temperature charting 4th hourly
- GRBS charting 6th hourly
- Syrup LACTULOSE 10ml
- Inj. PIPTAZ 4.5gm IV
- Inj. HAI ACTRAPID (SC)
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