1801006161,LONG CASE
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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.
Case
A 50 year old male patient farmer by occupation came to the OPD with
CHIEF COMPLAINTS :
- shortness of breath since 13 days
- complaints of edema involving both lower limbs since 9 days
-Decreased urine output since 9 days
HISTORY OF PRESENTING ILLNESS:
Patient is apparently asymptomatic 13 days back then he developed
-Shortness of breath which was insidious in onset and gradually progressive and know it has been progressed to Grade 4 ,which is aggrevated on lying down and walking and relieved on sitting position.
- He also had developed bilateral pedal edema ,since 9 which is insidious in onset and pitting type in nature and which was initially Grade 1 and know it has been progressed to Grade4
-He also had decreased urine output since 9 days.
No history of chest pain,palpitations,syncope,fever, cough ,hemoptysis,burning micturition and knee pains.
PAST HISTORY:
He has an history of fall from tree 10 years back
He was also diagnosed with Tuberculosis and Diabetis mellitus 3 years back
He also noticed swelling in both legs and consulted a doctor and was diagnosed with Chronic kidney disease.
-Not a known case of ; Hypertension, thyroid, Asthma
TREATMENT HISTORY:
Drug history:
-uesd NSAIDS intermittently to relieve neck pain
-Antitubercular therapy (for tuberculosis)
- Metformin 500mg three times a day(for Diabetis mellitus)
Past surgical history:
No history of any surgeries in the past
PERSONAL HISTORY:-
-Patient takes mixed diet
-Appetite is normal
-Sleep is adequate
-Bowel - regular
-Bladder- urinary output was decreased from 9 days
-Addictions : Drinks alcohol occasionally
-Daily routine:
The patient was a farmer by occupation and wakes up at 6 am and has his breakfast at 7 am goes to work ,completes work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm
He is now staying at home since the fall from tree due to low backache . He is not going to work anymore
FAMILY HISTORY:-
No significant family history
ALLERGIC HISTORY:-
No allergies to any kind of drugs or food items
GENERAL EXAMINATION:-
Patient is conscious, coherent, and cooperative well oriented to time place and person
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
-Pitting edema seen in both lower limbs
Supra clavicular: normal normal
Infra clavicular: normal normal
Mammary: normal normal
Infra axillary: normal decreased
Supra scapular: normal normal
Infra scapular: normal decreased
Inter scapular: normal normal
PERCUSSION:
Infra clavicular: resonant resonant
Mammary: resonant resonant
Infra axillary: resonant dullnote
Supra scapular: resonant resonant
Infra scapular: resonant dullnote
AUSCULTATION:
Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Supra scapular: Normal Normal
Infra scapular: Normal decreased
Inter scapular: Normal normal
Supra clavicular:. Normal Normal
Infra clavicular: Normal Normal
Mammary: Normal Normal
Axillary: Normal Normal
Infra axillary: Normal decreased
Infra scapular: Normal decreased
Inter scapular: Normal normal
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