CASE 2

July 21 2023

CASE 2

A 55 year old male presented to the hospital for dialysis

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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 55 year old male

shopkeeper by occupation

resident of Aruguru

presented to the hospital for dialysis

CHIEF COMPLAINTS:

severe lower back pain, bipedal edema, decrease during output and retention of stools

Since 3 years.

History of presenting illness

The patient was apparently asymptomatic 2 years ago when he developed severe lower back pain , insidious in onset, which was dull and constantly aching .

He had 2 episodes of fever before going to the hospital loss of appetite andhad a feeling of weight loss from 48 to 42 kgs.

There was no facial Puffiness

He was brought to a hospital in malakpeta where was diagnosed with ckd and was suggested to start on hemodialysis.

No history of hematuria, sob and increased ot decrease frequency of urination

N/k/c/o TB, thyroid, stroke

K/c/o CAD H/T EPILEPSY DM

Daily routine

He wakes up by 5.30 and takes a walk

Then he has his breakfast by 8.30 and goes to his shop. Comes back and has his lunch at 12 and then goes back again and comes to have tea at 4 and then has dinner at 9

Personal history

Diet : vegetarian . ( stopped eating non veg 30 yrs back)

Appetite : reduced.

Bowel and bladder movements: reduced but normal now

Sleep adequate

Addictions : none.

FAMILY HISTORY:

No family history.

GENERAL EXAMINATION:

Prior consent was taken and patient was examined in a well lit room.

Patient was conscious, coherent and cooperation.

Pallor present . No icterus, clubbing ,cyanosis.