A 58 yr old male c/o shortness of breath.
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I have been a case in order to make my skills better in understanding the "Patient's clinical data analysis". Making a note of all the necessary information like the history of patient's present illness, his medical history, his family history, diagnosis and treatment plan.
Chief complaint :
Patient came with a complaint of shortness of breath since one week.
Cough and cold since 3-4 days.
History of present illness:
Patient was apparently asymptomatic one year back, then he developed shortness of breath and cough.
He also had pedal edema and reduced urine output.
He approached a hospital then and was diagnosed as kidney failure and also heart failure ne yr back.
He was adviced dialysis but he rejected to take the treatment so was adviced conservative treatment.
Shortness of breath was relieving on siiting and is aggrevating on lying down.
Grade 3 shortness of breath is observed.
Sputum is mucoid and yellowish in color.
History of past illness:
Patient is a know hypertensive since one year and was on medication. (clonidone).
No history of diabetes, asthma, epilepsy.
Personal history :
Patient is a daily labourer.
Appetite - normal
Diet - mixed diet
Bowel movements - normal
Sleep - adequate
Addictions - patient is addicted to smoking
since 30 yrs. (Beedi-1 pack a day)
He was also alcohol but stopped since 1 yr.
No allergies.
General examination:
Patient is conscious, coherent, cooperative, and well oriented to time and place.
No pallor, icterus
No cyanosis and clubbing.
No lymphadenopathy
Pedal edema is seen.
Clinical pictures :
Vitals :
Pulse - 96 beats / min
Respiratory rate - 24 cycles /min
BP - 150/90 mm hg
SPO2 - 96%
GRBS - 126 mg
Temperatures:
Day- 11/01 12/01 13/01 14/01
Temperature - 99°F 98°F 97°F 97°F
15/01 16/01 17/01 18/01
96°F 97°F 98°F 98° F
Systemic examination:
Abdomen -
Inspection:
Shape - distended
Umbilicus - inverted
No dialated veins
No scars
Palpation:
No tenderness
No local raise in temperature
No palpable spleen and liver
Percussion :
No dull notes are felt
Auscultation :
Bowel sounds are heard.
Respiratory system-
Inspection :
Chest movements are symetrical
Trachea is in Central position
No scars
Palpation :
Trachea is in midline
Bilateral movements are confirmed
Vocal fremitus was decreased
Percussion :
Stony dull note is felt in left mammary region.
Auscultation :
Breath sounds are reduced on left side of the chest.
Vocal resonance is also reduced
Crepts are heard.
CVS : S1 and S2 and loud P2 is heard.
JVP is raised.
No murmurs are heard.
Provisional diagnosis :
Chronic renal failure
Heart failure
Investigations :
Blood picture :
ECG :
X ray :
Blood urea : 140 mg/ dl
Serum creatinine : 7.5 mg/dl
Blood sugar : 93 mg / dl
Calcium : 8.1 mg/dl
Uric acid : 9.3 mg%
Ultrasound :
2D echo :
Treatment:
Drugs:
Tab nodosis 500 mg BD
Tab Lasix 4 mg BD
Tab orofer
Inj. Erythropoietin 4000 IU weekly once
Budecort 0.5 mg
Tab nicardia retard 20 mg.
Dialysis.
