62YR OLD MALE WITH CHIEF COMPLAINTS OF SWELLING OF LEFT UPPER LIMB AND LEFT LOWER LIMB SWELLING SINCE 5 DAYS

 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

62YR OLD MALE WITH CHIEF COMPLAINTS OF SWELLING OF LEFT UPPER LIMB AND LEFT LOWER LIMB SWELLING SINCE 5 DAYS

HOPI-PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS AGO THEN HE DEVELOPED SUDDEN ONSET OF SWELLING IN LEFT UPPER AND LEFT LOWER LIMBA/W PAIN,PRICKING TYPE,NON RADIATING.NOH/O TRAUMA/INJURY TO HAND,NON PITTING TYPE OF EDEMA.H/O RESTRICTION OF MOVEMENTS @LEFT WRIST AND MCP,PLD,DIP JOINTS OF LEFT HAND.

PAST HISTORY-K/C/O CVA,LEFT HEMIPARESIS 3 YEARS BACK,RELIEVED

N/K/C/O HTN,DM,SEIZURES,TB,CAD,THYROID DISORDERS.

TREATMENT HISTORY-CVA 3 YEARS AGO ON ECOSPORIN AV 75/20

PERSONAL HISTORY-ALCHOL HISTORY-720ML/DAY WHISKEY SINCE 15 YEARS,STOPPED 3 YEARS BACK.

CHEWING TOBACCO SINCE 20 YEARS.

FAMILY HISTORY NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION

HEIGHT-180CM

WEIGHT-60KGS

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,OEDEMA.

PT IS C/C/C

AFEBRILE 

PR-86BPM

BP-120/80 MMHG

RR-18 CPM

SPO2-95%

GRBS-203 MG/DL

SYSTEMIC EXAMINATION

CVS-S1S2+ NO MURMURS

RS-BAE+,NVBS +

P/A-SOFT,PALPABLE

CVS-NFND +

INVESTIGATION:

Name  Value  Range	Name  Value  Range
BLOOD UREA   22-12-2023 05:38:PM 48 mg/dl 42-12 mg/dl	SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   22-12-2023 05:38:PM  SODIUM 135 mEq/L 145-136 mEq/L  POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L  CHLORIDE 100 mEq/L 98-107 mEq/L  CALCIUM IONIZED 1.09 mmol/L mmol/L
LIVER FUNCTION TEST (LFT)   22-12-2023 05:38:PM  Total Bilurubin 0.95 mg/dl 1-0 mg/dl  Direct Bilurubin 0.17 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 330 IU/L 35-0 IU/L  SGPT(ALT) 141 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 137 IU/L 128-53 IU/L  TOTAL PROTEINS 7.1 gm/dl 8.3-6.4 gm/dl  ALBUMIN 3.95 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.25

DIAGNOSIS:

K/C/O CVA WITH LEFT HEMIPARESIS(RESOLVED)

WITH DENOVO DIABETES MELLITUS TYPE 2

TREATMENT:

INJ.IV FLUIDS NS@75ML/HR

TAB.ECOSPORIN 75MG PO/HS

TAB.ATORVASTATIN 20 MG PO/HS

TAB.TORSEMIDE10MG+SPIRONOLACTONE 50MG PO/OD

TAB.METFORMINE 500 MG PO/BD

TAB.AUGMENTIN 625 MG PO/BD

TAB.ACECLO PLUS PO/BD

ADVICE AT DISCHARGE:

TAB.ECOSPORIN 75MG PO/HS

TAB.ATORVASTATIN 20 MG PO/HS

TAB.METFORMINE 500 MG PO/BD

TAB.PAN 40 MG PO/OD

TAB.ACECLO PLUS PO/BD