This is an 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 patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient centered online learning portfolio and your valuable comments on 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.
Presenting complaints:
Patient came to casuality with the cheif complaints of sob since 10 days
Complaints of edema of upper limbs and lower limbs since 6 days
Decreased urine output since 6 days
HOPI:
Patient was apparently asymptomatic 1 year back then he had sob which is intermittent type then he was diagnosed with CKD 1 year back.
10 days back he had sudden onset of sob, which is GRADE IV, orthopnea present, pnd present
Edema of both upper and lower limbs
Lower limb edema which is pitting type upto thigh
Asymptomatic 10 years ago. History of fall from tree. Developed low backache and neck pain then 3 years back fever, cough loss of appetite for 2 months diagnosed with tuberculosis and diabetes. ATT for 6 months and on OHA since then
Seasonal SOB with wheeze (since 3 years) on and off and with CKD 1 year ago. Increased sob and edema since 10 days decreased urine output for w days
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