GENERAL MEDICINE: short 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.


A 58 yr old male patient labour by occupation Came to OPD on 11 th January at 4:57 pm.

CHEIF COMPLAINT:
  Shortness of breath since 7 days 
  Cold & cough since 6 day 

HISTORY OF PRESENT ILLNESS:
 - Patient was apparently asymptomatic 1 yr back, then he developed Shortness of breath, cough, pedal edema, decreased urine output, distended abdomen
- He was taken to hospital and diagnosed to have renal failure and heart failure 
- He was suggested dialysis but refused and was on conservative management
- SOB grade III relieved on sitting position ,increases while lying 
- orthopnea,chest pain, palpitations 
- cough,cold, fever 
- sputum is mucoid and froathy 

HISTORY OF PAST ILLNESS:
 Is a K/C/O HTN since 1 yr (on medication with clonidine)
Not a K/C/O DM, Asthma, CAD, Epilepsy

PERSONAL HISTORY:
   Diet : mixed
   Appetite: normal
   Sleep : adequate
   Bowel and bladder movements: regular
   No addiction : Alcoholic stopped 1yr back 
   No allergies

GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative
Well oriented to time and place 
- No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of fingers 

- pedal edema subsided


VITALS:
Temperature-afebrile
Pulse rate -96 bpm
Respiration rate -16cpm
Bp-140/80 mm Hg
Spo2 -96%

SYSTEMIC EXAMINATION:
CNS :
.NAD( no abnormality detected)

CVS :
-S1, S2 are heard
- No murmur
RESPIRATORY SYSTEM :
INSPECTION :-
     Chest movements: Bilaterally symmetrical
Trachea is central in position 

 PALPATION:-

All inspiratory findings are confirmed
Trachea is central in position

 PERCUSSION:-
     Stony dull heard in left mammary region

 AUSCULTATION:-
 Breathe sounds : diminished on left side (mammary, infra scapular region)
  Vocal resonance :decreased 
 

🔹ABDOMEN:
- shape of abdomen: distended 
- No engorged veins, scars
- Tenderness : No
- Liver : not palpable
- Spleen : not palpable
- Bowel sounds present

PROVISIONAL DIAGNOSIS:
  Heart failure
 Pleural effusion 

CLINICAL IMAGES:
INVESTIGATIONS:
  ECG:


 ultrasound:

Chest x - ray 

Hemoglobin
Blood sugar Random
Creatinine
Blood Urea
HBsAg
Anti Hcv Antibodies
Hemogram
Blood grouping
Phosphorus
Serum Calcium
TREATMENT
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Inj. Erythropoietin 

DIAGNOSIS:
Chronic kidney disease
Bilateral pleural effusion 
 Heart failure
Anemia









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