67 Y/ M CAME WITH C/O CHEST PAIN SINCE 3 DAYS C/O NECK PAIN SINCE 3 MONTHS

This is an a 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. 


C/O CHEST PAIN SINCE 3 DAYS

C/O NECK PAIN SINCE 3 MONTHS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN DEVELOPED NECK PAIN INSIDIOUS IN ONSET DRAGGING TYPE RADIATING TO SHOULDER A/W GIDDINESS, TINGLING AND NUMBNESS OF UPPER LIMBS

CHEST PAIN INSIDIOUS ONSET NO AGGRAVATING FACTORS, RELIEVED ON MEDICATION A/W BREATHLESSNESS

H/O ABDOMINAL PAIN, RT LOIN PAIN

H/O BURNING MICTURITION

H/O BELCHING AND BLOATING

NO H/O FEVER, PALPITATIONS AND PEDAL EDEMA

NO H/O FACIAL PUFFINESS

PAST HISTORY

H/O SURGERY FOR RENAL STONES 2 TIMES IN RIGHT KIDNEY  7 YRS BACK

H/O SURGERY FOR CATARACT BOTH EYES 4 YRS BACK

K/C/O DM II SINCE 3 YEARS GLIMI M1 PO OD

N/K/C/O HTN, CVA, CAD, THYROID DISEASE ND EPILEPSY, TB

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR , BURNING MICTURATION 

ADDICTIONS: ALCOHOL 90 ML TWICE A WEEK FOR 20 YRS

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:130/70 MM HG

PR:80 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

UROLOGY REFERRAL DONE ON 29/1/24 I/V/O B/L RENAL CALCULI AND LEFT RENAL CYST.

ADVICE: TAB PCM 650 MG PO BD

SYP ALKASTONE PO BD  15 ML IN HALF GLASS WATER FOR 3 MONTHS

INVESTIGATIONS:

HBsAg-RAPID 27-01-2024 04:26:PM Negative

Anti HCV Antibodies - RAPID 27-01-2024 04:26:PM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 27-01-2024 04:26:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

RFT 27-01-2024 04:26:PM

UREA 15 mg/dl 50-17 mg/dl

CREATININE 1.2 mg/dl 1.3-0.8 mg/dl

URIC ACID 5.0 mg/dl 7.2-3.5 mg/dl

CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.8 mg/dl 4.5-2.5 mg/dl

SODIUM 137 mEq/L 145-136 mEq/L

POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L

CHLORIDE 99 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 27-01-2024 04:26:PM

Total Bilurubin 0.75 mg/dl 1-0 mg/dl

Direct Bilurubin 0.14 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 15 IU/L 35-0 IU/L

SGPT(ALT) 15 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 203 IU/L 119-56 IU/L

TOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.22 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.99

POST LUNCH BLOOD SUGAR 27-01-2024 04:28:PM 249 mg/dl 140-0 mg/dl

HBA1C - 6.8

FBS 137 MG/DL

HB - 14 GM/DL

TLC - 7200

PTL- 2.06

USG DONE ON 29/1/24

FINDINGS:

E/O FEW CALCULI, LARGEST 4-5MM IN MID POLE AND LOWER POLE OF RIGHT KIDNEY

E/O 13 X 12 MM CYST NOTED IN MID POLE OF LEFT KIDNEY

E/O FEW CALCULI , LARGEST 2-3MM IN LEFT KIDNEY.

IMPRESSION : B/L RENAL CALCULI

 LEFT RENAL CYST

DIAGNOSIS:

ACID PEPTIC DISEASE

DIABETES MELLITUS

CERVICAL SPONDYLOSIS



TREATMENT:

TAB GLIMI M1 1--0--0 CONTINUE

TAB PAN OD 1--0--0 BEFORE BREAK FAST FOR 5 DAYS

SYP SUCRALFATE 10 ML TID  1--1--1

TAB ULTRACET 1--0--1 FOR 5 DAYS

TAB. BENFOMET PLUS PO/OD 0--1--0  FOR  DAYS

TAB SHELCAL 0--1--0 FOR 15 DAYS

TAB PCM 650 MG PO BD FOR 5 DAYS 1--0--1

SYP ALKASTONE  15 ML IN HALF GLASS WATER PO BD FOR 3 MONTHS 1--0--0

AVOID SPICY FOOD

COMPLETE ABSTINENCE OF ALCOHOL 


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