22/Male with renal failure
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Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.
CONSENT AND DEIDENTIFICATION :
The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
PRESENTING COMPLAINTS:
A 57-year male clinically presented with complaints of:
• Fever for 15 days.
• Pedal oedema and abdominal distinction since 5 days.
• Constipation for 3 days.
• Altered sensorium for a day.
HOPI:
A 57-year male was clinically brought to the casualty with complaints of high-grade intermittent fever associated with chills and rigours for the initial 2 days for which he sought consultation at a local RMP and was treated systematically with oral medications. On day 3 of his illness, he was diagnosed with typhoid and was treated with Intravenous antibiotics for 8 days, he was discharged from the hospital after he got relieved from the symptoms.
History of pedal oedema and abdominal distention since 5 days associated with abdominal pain for which he sought consultation at a private hospital and he underwent 1 hemodialysis after placement of left Internal Jugular vein central line because of deranged RFT. History of constipation for 3 days. History of altered sensorium since a day. He was oriented to time, place and person, but has delayed response and is irritable, talking to himself. Now admitted for further management and treatment.
PAST ILLNESS:
Known case of hypertension diagnosed 6 years ago.
Known case of Type 2 Diabetes mellitus diagnosed 6 years ago.
No other comorbidities.
No surgical history.
DRUG HISTORY:
HTN: TAB. LOSAR H 1 tablet once daily after food at 8 AM.
DM: TAB. GLIMI M1 1 tablet once daily after food at 8 AM.
PERSONAL HISTORY:
Moderately built and nourished.
Appetite lost.
Bowels are irregular.
Bladder regular.
No allergies.
Chronic alcoholic (whisky) 180ml once or twice a week.
Chronic smoker stopped 6 years ago after being diagnosed with Hypertension.
GENERAL PHYSICAL EXAMINATION:
The patient was conscious, cooperative and oriented to time, place and person but was an irritable and delayed response to speech.
Pedal oedema of grade II, pitting type.
No pallor, Icterus, cyanosis, clubbing, Lymphadenopathy.
Left IJV line Insitu.
VITALS:
GCS: E3V4M6 (13/15).
Temp: 99°F; PR: 108bpm; BP: 140/90mmHg; RR: 24cpm; SpO2: %@RA; GRBS: 273mg/dl.
CVS: S1, S2+; R/S: BAE+, fine crept at bilateral IAA; bilateral diffuse rhonchi.
P/A: soft, diffuse tenderness, guarding present.
P/R: No faecal matter noted.
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