Gm case 2

 

71 year old male with decreased urinary output, right lower limb cellulitis and hypotension

September 25,2023

Hi, I am Alekhya, 5th Sem Medical Student.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.”

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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS:

Patient came with c/o decreased urinary out put since 4 months  with right lower limb cellulitis since 1 month 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4 months ago then he had decreased urinary output, patient had thorn prick on 27/8 /23 and he got admitted in local hospital then patient developed swelling in right lower limb with boils over right ankle and then admitted to ou; Casuality. 

Past history:

K/C/O DM since 10 years

Not a k/ c /o HTN,thyroid,TB,Epilepsy 

Family history: Not significant 

Allergic history:-

No history of any kind of allergies to food/drugs

GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY

VITALS:

Temperature: 98.8 F 

Pulse rate: 81bpm

Blood pressure: 90/60mmHg

Respiratory rate: 30cpm

SYSTEMATIC EXAMINATIONS:-

CVS:S1 S2+,NO MURMURS

CNS: NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY