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I've 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.
Case:
A 64 yrs old male patient from labourer by occupation came to the opd with chief complaints of
shortness of breath ,
bilateral pedal edema and
decreased urine output since 3days.
History of presenting illness
Patient was apparently asymptomatic 1week and then he developed shortness of breath which was insidious onset gradually progressive (grade -2)
Bilateral pedal edema since 1 week pitting type.
H/o decreased urine output since 3days.
No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections
No h/o palpitations, syncope, fever.
No h/o burning micturition , hematuria
No history suggestive of hypo or hyperthyroidism
Past history ::
Patient is a known case of Hypertension since 3yrs and is on regular medication.
Patient had a history of tuberculosis 2 years back which was detected by bronchoscopy and started on ATT drugs for 1 year.
One month back patient had a history of vomiting dizziness,and weakness of left upper limb , lower limb and decreased response for 5 hours and was admitted in local hospital and CT was done and it showed capsule meningeal bleed secondary to cerebrovascular stroke.
In view of elevated serum creatinine and metabolic acidosis patient was advised on hemodialysis twice weekly. His last dialysis was 5 days back.
Not a known case of asthma, and epilepsy.
Personal history :
Diet-consumes mixed diet
Appetite-Normal appetite
sleep-adequate
Bowel and bladder are regular
-He is a chronic alcoholic and habit of smoking since 30 years and stopped 6 years back.
Family history:
No similar illness in the family
Low socioeconomic status
no significant family history
Treatment history :
medication for hypertension since 4yrs tab along 10mg .
General examination :
patient is coherent, cooperative ,drowsy,slightly oriented to time place person comfortably lying on bed
moderately built and nourished.
pallor present
edema present
No signs of icterus cyanosis clubbing koilonychia ,generalised lymphadenopathy,
JVP- normal
VITALS
pulse- 68 /min no radio radial delay and radiofemoral dealy
Blood pressure -140 /90 mmHg right arm supine position
No significant postural fall
Respiratory rate 18 cycles per minute
Temperature afebrile
Local examination
CVS
Inspection :
shape of the chest normal , symmetrical ,no deformity
Trachea appear to be central ,no precordial bulge
No visible impulses scars sinuses dilated veins in any part of the thorax
Palpation :
all inspectory findings confirmed by palpation
Trachea is central
Apex beat is felt at 5th intercostal space
No pericardial rub
Percussion :
No dull note noticed.
Auscultation :
S1 S2 heard no murmurs
Respiratory system :
bilateral air entry present
Normal vesicular breath sounds heard no added sounds
Per abdomen :
soft ,non tender, no organomegaly ,no free fluid
Bowel sounds heard
Hernial orifices are normal
CNS::
1) level of consciousness- drowsy,arousable
2)speech- no response
3)there are no signs of meningeal irritation like neck stiffness and kerning sign is negative
4)Cranial nerves examination is normal
5)motor system
Tone -hypertonia present in upper limbs and lower limbs
Power -
UL . Rt. Lt
-4/5. -2/5
LL
4/5. 2/5
Gait - hemiplegic gait
Reflexes -
Superficial reflexes are normal
Plantar flexor reflex present
Deep reflexes -knee and ankle reflexes are exaggerated on both sides
PROVISIONAL DIAGNOSIS-
Based on examination left sided hemiplegia is noted , a known case of hypertension , chronic kidney disease on MHD.
INVESTIGATIONS
HEMOGRAM : hemoglobin reduced
Complete urine examination-
Renal function test urea and creatinine raised
Liver function test
ECG
12 leaded ecg
Heart rate : 84bpm
Normal QR segment
Normal PR segment
Lead II normal
P wave
Qrs complex
ST segment
T wave
Chest x ray ::
Ultrasound report. Renal parenchymal disease grade II
Treatment history ::
TREATMENT:
SALT AND FLUID RESTRICTION
Provisional diagnosis:
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