Short case

 Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 

A 70 year old male patient came to the opd with the chief of shortness of breath, bilateral pedal edema, difficulty in breathing on lying down.

Date of admission:16/01/2023

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1year back then he developed pedal edema upto knees which was pitting in nature and shortness of breath (NYHA class 2) for which he went to a local  hospital and was diagnosed with renal failure and started on conservative management.2months back he developed shortness of breath and bilateral pedal edema pitting type and orthopnea.

HISTORY OF PAST ILLNESS:

Hypertension since 16years(on nicardia retard 10)

Diabetes since 6years(on MET XL 50)

History of renal failure and dialysis 1year back

Not a known case of tuberculosis, epilepsy, asthama

No history of surgery

DRUG HISTORY:No allergies to known drugs

PERSONAL HISTORY:

Married

Diet: mixed 

Appetite:normal

Sleep: adequate 

Bowel and bladder:normal

No addictions

FAMILY HISTORY:NO significant family history 

GENERAL EXAMINATION:

Patient was concious coherent cooperative and well oriented to time place and person.

Pallor seen

No cyanosis icterus clubbing generalized lymphadenopathy 

Bilateral pedal edema seen upto knee

Vitals:

Built: moderate 

Temperature: afebrile

Pulse rate:86bpm

Respiratory rate:18cpm

BP:110/80mm hg

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

INSPECTION:

Chest is bilaterally symmetrical

Trachea -central

No drooping of shoulders

No supraclavicular hollowing 

No use of accessory respiratory muscles

No scars,sinuses,dilated veins, nodules

Movements with respiration are bilaterally symmetrical

PALPATION:All inspectory findings are confirmed 

Trachea-central

No intercoastal widening or crowding of ribs

Whole thorax measurement:35inch

Hemithorax:17.2

Vocal fremitus:normal on both sides 

Percussion:

Resonant,dullness from 5th intercoastal space

AUSCULTATION: vesicular breath sounds

No added sounds,

CVS:

INSPECTION:chest is symmetrical

No precordial bulge

No kyphoscoliosis,no dilated veins,scars

Apical impulse not seen

No other visible pulsations

PALPATION:

No kyphoscoliosis 

Apical impulse at 5th left intercoastal space 

AUSCULTATION:S1&S2 heard

No murmurs,no added sounds 

ABDOMEN:

INSPECTION:Shape:obese

Flanks-full

Umbilicus: central, inverted

No scars,sinuses,scratches,dilated veins

Movements are symmetrical ,normal hernial orrifices

PALPATION:no tenderness,no rise of temperature no palpable masses,no organomegaly

PERCUSSION:NO free fliud,no ascites

AUSCULTATION:bowel sounds heard,no bruit 

CNS: speech: normal

Gait: normal 

No neck stiffness 

Sensory system :normal

Motor system :normal 

No cerebellar signs

Provisional diagnosis:cardiac failure, CKD on mhd

INVESTIGATIONS:

Treatment:Inj lasix 40mg iv/bd

Inj.Erythropoietin 4000IU sc once weekly

Inj.pan 40mg iv/od

Inj.optineuron 1ampule in 100ml NS IVSTAT

Tab.nodosis 500mg po/bd

Tab orofer -xt PO/BD 

Tab Shelcal  500mg PO/BD

Final Diagnosis:ckd on mhd