short case
65Y/M PATIENT WITH COMPLAINT OF SOB AND DISTENSION OF ABDOMIN AND PEDAL EDEMA
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:
A 65 years old male patient ,resident of suryapet ,mason by occupation,came to the casualty with chief complaint of :
Increased shortness of breath since 5 days
Distension of abdomen and pedal edema since 1 week
HISTORY OF PRESENT ILLNESS:
->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
->1 week back-
shortness of breath which is insidious in onset, progressed from grade II- III(NYHA)
orthopnea+
no h/o PND, no seasonal variation, no h/o wheezing
chest pain occasionally present which is radiating to arms, relieved after taking medication.
palpitations are absent
distension of abdomen- 2 months
decreased urine output, appetite is normal, burning micturition, pedal edema since 3 months, piiting type and increased while standing also.
HISTORY OF PAST ILLNESS:
Not a k/c/o TB, asthma, epilepsy
History of diabetes mellitus
FAMILY HISTORY:
no relevant family history
PERSONAL HISTORY:
Appetite:Normal
Diet:Mixed
Bowel and bladder : Regular
Addiction: patient have an habit of smoking since 30years ( 1 pack per day)
Marital status: married
Occupation:Mason(stopped one year back)
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
-Speech is normal.
-no abnormality detected
CVS examination:
-S1, S2 are heard.
-No murmurs
Respiratory 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:
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 is Distended
Surface shows No Dilated veins, visible peristalsis, engorged veins, scars.
Palpation:
Liver and spleen not palpable
Percussion:
Resonant note is heard
Auscultation:
Bowel sounds are heard
Investigation:
Provisional diagnosis:
- CKD secondary to diabetic nephropathy
TREATMENT:
Tab Lasix 40mg
Tab Nodosis 500mg
Tab Orofer
Cap BIOD3
Tab Shelcal
Tab Nicardia 10mg
Tab Carvidilol
Salt fluid restriction
Monitor vitals
