65 YEAR OLD MALE WITH SHORTNESS OF BREATH

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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 diagnosis and treatment plan.

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HOD-DR.RAKESH BISWAS 

PG-DR.KRANTHI 

PG-DR PRACHETAN

 65 year old male farmer by occupation came with chief complaints of 

• Pedal edema since 2 days
• Facial puffiness since 2 days
• Shortness of breath since 2 days

History of presenting illness 

-Patient was apparently  normal till 2016,

• In 2017,During routine health check up patient was diagnosed with Hypertension and was started on antihypertensive medication by local physician.

-In 2018 patient had complaints of pedal edema and breathlessness for which he sought for consultation and was diagnosed with chronic kidney disease and  was initiated with conservative management.

•  He was also advised some dietary modifications which he followed for 1 year. 

-He stopped Anti Hypertensive medication as per physicians advice after 2months.

-12 days ago, he had complaints of Shortness of Breath and facialpuffiness went to private hospital in Miryalguda and was advised for dialysis .

He underwent dialysis for 4 times

Course in the hospital 

-on 6/7/2023  he developed Bilateral pedal edema pitting type below the knees  associated  with facial puffiness and Shortness of breath grade 2 MMRC

No aggrevating and relieving factors 

Not associated with cough,palpitations, sweating 

No H/o reduced urine output,hematuria.

-on 8/7/2023

During dialysis patient developed fever with chills

After undergoing dialysis patient was found hypotensive in the ward,in view of hypotension patient was shifted to ICU.

Vitals at 10 15Am

Bp-60/40 mm hg

PR-136 bpm

RR-29 cpm

Spo2 -97 on RA

Temp 104.4

Fever spikes were present.

Patient BP was 80/40 mmhg ìntra dialysis 

Post dialysis patient BP was 60/40  mmhg 300 ml bolus was given.

On 9/7/2023

At around 5 pm patient BP was maintained with noradrenaline 

Daily routine 

Patient wakes up around 7AM early in the morning 

At around 10 AM after having breakfast  he helps in routine household activities.

He goes for work in paddy fields occasionally  then he takes lunch usually rice and dal at around 1 pm

(He followed strict dietary modifications like avoiding non veg and spicy food as per physicians advice for about 1 year)

He sleeps for 1 hour in the afternoon and has dinner  usually rice and vegetable curry around 9pm and goes back to sleep at 10 pm.

Past history 

- No H/O DM, Asthma, Epilepsy, TB, CVA, CAD,thyroid disorders. 

 

Personal history 

Diet - mixed

Appetite-normal 

Bowel and bladder-Regular

Addictions-Occasional toddy drinker

No allergies 

Family history-Not significant 

GENERAL EXAMIANTION

 Patient is conscious coherent and coperative well oriented to time place and person 

No signs of Pallor cyanosis clubbing lymphadenopathy Icterus. 

SYSTEMIC EXAMINATION-

Cardiovascular system 

-S1S2 heard, no murmurs.

Respiratory examination- Bilateral air entry present, Normal vesicular breath sounds heard.

Per Abdomen-- soft, non tender,no organomegaly.

 

Central Nervous Examination- Higher mental functions intact. No focal neurological deficit.

Investigations on 8/7/2023

Hb-8.1gm /dl

Serum urea 100

Serum creatinine 6.4mg/dl

Investigations on 6/7/2023

CBP

CUE

BLOOD GROUP 

SERUM CREATININE 

SERUM IRON

RBS

BLOOD UREA

HCV

HBSAG

USG

Bilateral grade 3 RPD changes with renal cortical cysts

On 8/7/2023

HEMOGRAM 

RFT

Treatment:

1.TAB NODOSIS 500MG PO/BD

2.TAB LASIX 40MG PO/BD

3.TAB OROFER XT PO/OD

4.TAB SHELCAL PO/OD

5.BIOD3 PO/OD ONCE A WEEK

6.SYP.POTCHLOR 15ML IN 1 GLASS OF WATER PO/BD