A 70Y Old Male with Left LL Cellulitis

This is an Online E Log book to discuss our patient's de-identified health data shared after taking his 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 patient's with collective current best evidence based inputs.

M. K. Farhan

Roll no. 4

I've been given this case to solve in an attempt to understand the topic of "Patients 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.

I have taken some inputs from the elog about the same patient which have been mentioned in the above link

4th September, 2023.

Case Discussion:

A 70yr old male came with C/o swelling over right lower limb

c/o pain over Right LL

c/o shortness of breath (Grade 2) since 2 days

No aggravating and relieving factors.

History of Presenting Illness :

Pt was apparently alright 2 days back then he developed blebs and swelling in Rt.LL

H/o trauma present and subsided on medication

Pain was sudden in onset and gradually progressive with no aggravating and relieving factors

K/c/o DM T2, and HTN since 1 year and on regular treatment.

Had previous surgical history for Rt. Inguinal hernia 15 years ago.

On 2nd of this month at night 10.00 the patient complaint of sudden SoB and was taken to for ECG

I/V/O SoB and ECG it has been diagnosed as Cardiomyopathy

History of past illness:-

Not a k/c/o epilepsy, asthma, TB and Thyroid.
patient has H/o heat and Cold intolerance
patient has H/o recurrent oral ulcers

Personal history:-

Appetite normal
Mixed diet
Sleep normal
Bowel and bladder normal
Addictions- none

General Examination:-

The patient was examined in well lit room after taking his consent.

The patient was conscious, coherent and co operative. He was well Oriented to time, place and person
No pallor, interus, cyanosis, clubbing, lymphadenopathy and oedema.

Vitals:-

Temperature: afebrile
Blood Pressure: 110/70 with inotropic
Pulse Rate: 106 bpm
SpO2: 97% at RA
P/A- Soft

Systemic Examination:-

CVS- S1, S2+
RS- BAE+, NVBS
P/A- Soft and Tender
GIT- Bowel sounds+
CNS-

Investigations:-

Patient was advised to take these medications:-

INJ PIPTAZ 4.45gm IV/ TID

INJ Clindamycin 600mg IV/ TIM

INJ Noradrenaline 8ml +42 ml NS @9ml/ hr

INJ Dobutamine 5ml + 45ml NS @ 6ml/hr

INJ Lasix Infusion @ 5mg/hr

INJ Thiamine 20mg in 100ml NS IV/BD

INJ HAI s/c TID according to GRBS

Moniter vitals hourly

Tab Met XL 12.5mg PO OD

Comments

43F Patient came to opd with c/o Bilateral pedal edema

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. 43F Patient came to opd with c/o Bilateral pedal edema since 1 month. Patient was apparently asymptomatic till 1 month ago then she developed c/o B/L pedal edema (pitting type, extending upto the knee) and chest discomfort (now subsided) now patient has c/o tingling of Rt. Upper limb. Pt has come for regular checkup of HTN& DM Had H/o UTI 1 month ago Numbness in Rt upper limb and Rt lower limb since 1 month. PAST HISTORY:k/c/o Diabetes since 10 yrs and is on Insulin HAI 15U- 20U- 25U. k/c/o hypothyroidism since 6 yrs and is on Tab. Thyroxine 125mg PO/OD k/c/o Hypertension since 2

A 50M with C/o Bilateral Pedal Edema

A 50Y M Came with C/o Pedal Edema since 1 week HOPI:- Patient was apparently asymptomatic 1 Year back then he developed back pain for which he went to local hospital and diagnosed to have CKD. He was on Conservative management, 3 months back he had Pedal edema and started on hemodialysis since May 25 which was his last follow up. Pedal edema is present Blood transfusion of PRBC done on 02/09/23 Dialysis was done on:- 21/8/2023 24/8/2023 30/8/2023 02/9/2023 04/9/2023 23/9/2023 27/9/2023 30/9/2023 02/10/2023 07/10/2023 Past History: K/C/O CKD since March 2023 K/C/O DM2 since 4 years on Insulin ( Irregular Medication) K/C/O HTN, CVA, CAD, Epilepsy Surgical history:- 4 years back 2nd right toe amputation done (Diabetic) In March RIGHT IJV was placed and removed in May. On Examination:- Patient was conscious, coherent and cooperative No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy Vitals:- Temp- 98.4F PR- 96 BPM RR- 18 CPM

A 70 YR OLD MALE WITH ALTERED SENSORIUM AND HYPONATREMIA.

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 inputs on the comment box is welcome." CASE: A 70 year old male came with chief complaints of : 1) Altered behaviour since afternoon. 2) Involuntary movements of the both upper limbs and lower limbs since 4pm along with loss of speech and involuntary movements of the mouth. HOPI: Patient was a security guard by occupation in Hyderabad 20 years back and there sons brought him to their village 20 years back and was doing nothing since then. He was normal till 1 month back and started developing decr

171 MK Farhan, E Log Cases

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