This is 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 patients clinical problems with collective current best evidence based inputs. 

This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .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 diagnosis and treatment plan

( All the information have been collabated from patient).

Case discussion;

Following is the view of my case

Case discussion ;

A 58 old male daily wage labourer by occupation came to the hospital .

Chief complaints ; shortness of breath since 1 month.

Decreased urine out put since 1month

Pedal edema since 3 months

Chest pain since 1 month

Facial puffiness since 1 month

History of present illness;

The patient was alright 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos

2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months .

Also developed rt upper limb swelling since 4 days.

 Swelling in the left chest region, gradually progressing to current size, since 4 months

Back pain since 2 months, subsided on medication (T. Ultracet)

30 days back - developed

Shortness of breath ,

Grade II-III progressed to Grade IV since 30 days along with orthopnea .

Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.

Even after dialysis, chestpain did not subside

Ecg was done(18/01/22): ST elevations noted in V2,V3,V4

Repeat ecg done (on 19/01/22): 

ST elevations subsisded

C/o. generalized body pains

No c/o palpitations, giddiness, cold, cough, burning micturition

PAST HISTORY -

Known case of Hypertension since 4years on Tab nicardia 20mg OD

Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history:

Appetite- decreased

Diet- mixed

Bowel movement- Regular

Alcoholic stopped 4 yrs ago

Non smoker

On examination:

Pt is C/c/c

No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy

B/L pedal Edema(pitting type) present

Vitals

Pr:94bpm

Bp:120/80

Spo2:97% at RA

Temp - Afebrile

Systemic examination

CVS - S1,S2 +

RS - BAE + 

CNS - NAD

P/A- Soft, non tender

Pleural fluid LDH 98

Serum LDH 294

Ratio-0.3

Pleural fluid protein-2.0

Serum total protein -5.9

Ratio-0.3

Total count -100cells

Differential count- 

80% lymphocytes

20% neutrophils

Transudative effusion

Provisional Diagnosis -

CKD on MHD

Heart failure secondary to coronary artery disease(recent lateral wall MI)

?Spondylodiscitis

Hypertensive since 4yrs

?left upper limb lymphedema (secondary to AV fistula surgery)

Treatment ;

✓ fluid restriction 1.5 litre/ day

✓ salt restriction <2g/day

✓ tab lasix 40mgbd

✓tab metoz 5mg of

✓ tab nicardia 20mgbd

✓ tab arkamine 0.1 mg TID

✓ tab orofer-xt of

✓ tab nodosis 500mg bd

1-*-1

✓ tab shelcal 500mg of *-1-*

✓cap bioD3 0.25 mg of

✓ tab pan-d 40mg of

✓inj erythropoietin 4000u sc once weekly

✓ moniter vitals