general medicine long case

     This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 COMPLAINT:

 65 years old male patient came to the casualty with chief complaint of shortness of breath since 5 days and distension of abdomen and pedal edema since 1 week

HOPI: patient was apparently asymptomatic 1year back

March 2022- patient was taken to private hospital with c/o shortness of breath, pedal edema, distension of abdomen and fever and was diagnosed to have renal failure and heart failure, and was started on conservative management.

June 2022- patient had similar episodes and had HB of 5 approx and 20 prbc and transfusion was done

diagnosed as anemia secondary to CKD 

NO H/O of Malena, hematemesis, decreased apetite 

since 1week- 

shortness of breath which is insidious in onset, progressed from grade II- III(NYHA) 

orthopnea+ 

no h/o PND, no seasonal variations

palpitations (-) 

distension of abdomen-  1  month

decreased urine output, 

appetite is normal, burning micturition, pedal edema since 3 months, pitting type and increased while standing and relieved on lying down

HISTORY OF PAST ILLNESS:

Not a k/c/o TB, asthma, epilepsy 

h/o DM since 8 years ( on medication) 

h/o HYTN  since 7years

H/O CAD

FAMILY HISTORY:not significant

PERSONAL HISTORY:

-Appetite:Normal

-Diet:Mixed

-Bowel and bladder  : Regular

sleep- adequate

-Addiction: patient smoking since 30years ( 1 pack per day)

GENERAL EXAMINATION:

-Patient is conscious, coherent and cooperative.

-Well oriented to time, place and person.

Moderately built and well nourished.

-Pallor: yes

-Icterus: no

-Cyanosis: no

-Clubbing of fingers: no

-Lymphadenopathy: no

-Pedal oedema: yes 

VITALS: Temp: 99F

-BP: 150/90mmHg 

-PR: 76bpm

-RR: 16 cpm

-SpO2: 100% 

SYSTEMIC EXAMINATION:

CNS examination:

motor and sensory system- normal

-Patient is conscious, coherent and cooperative.

-Speech is normal.

-NAD(no abnormality detected)

CVS examination:

-S1, S2 are heard.

-No murmurs heard

Respiratory system examination:

INSPECTION:

Size and shape: bilaterally symmetrical and elliptical 

Position of Trachea:central

No supraclavicular hollowing

No usage of accesory muscles of respiration

Apical impulse is not seen

Chest expansion: symmetrical

PALPATION:

Trachea:midline 

No intercoastal widening or narrowing

Chest movement: symmetrical

Measurement of chest expansion:

Whole thorax:55cm

Right Hemi Thorax:28cm

Left hemi thorax : 27cm

Position of apical beat at 5th intercostal space , 1 inch medial to midclavicular line.

Tactile vocal fermitus is equal on both sides

PERCUSSION:

No tenderness over chest wall, no crepitations, no palpable added sounds, no palpable pleural rub

AUSCULTATION:

-.Normal vesicular breath sounds heard

dyspnoea - present

wheeze- present

crepitus - present

Abdomen:

Inspection:

Shape of Abdomen:Distended

free fluid - present

No Dilated veins, visible peristalsis, engorged veins, scars.

Palpation:

Liver : not  palpable 

Spleen: not palpable

Percussion:

Resonant note heard

Auscultation:

Bowel sounds heard. 

Provisional diagnosis:

- CKD secondary to diabetic nephropathy

CLINICAL IMAGES:

INVESTIGATION: 19/1/23

ULTRASOUND:

ECG:

 CHEST X Ray

TREATMENT:

Tab Lasix 40mg

Tab Nodosis 500mg

Tab Orofer

Cap BIOD3

Tab Shelcal

Tab Nicardia 10mg

Tab Carvidilol

Salt fluid restriction

Monitor vitals