1601006172 SHORT CASE

 

55 year old with difficulty in breathing



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 diagnosis with a treatment plan. 

Hall ticket number: 1601006172

 This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent. 

Short Case 

A 55 year old gentleman hailing from Miryalaguda, laborer by occupation came with

Chief complaints:  

Difficulty in breathing since 4 days. 

History of present illness: 

He was apparently asymptomatic 4 months back. 

1. Then he developed fever, which was:

  • Insidious in onset
  • Intermittent 
  • Non progressive 
  • Low grade 
  • Not associated with chills or rigors 
  • No diurnal variation 
  • Relieved by medication briefly 
As the fever wasn’t subsiding, he went to Miryalaguda hospital where he was diagnosed with Chronic Kidney Disease and was prescribed medication for the same. 

2. 2 months back, he developed Bilateral pitting edema, which was initially limited to ankles (grade II) and then progressed till the knees (grade II)

3. 4 days back, he developed dyspnoea on 21st April around 2 AM in the night.
  • Sudden in onset
  • Grade: IV 
  • Postural variation: present (increased on lying down) 
4. 3 days back he developed cough which was sudden in onset
  • Sudden in onset 
  • Dry in nature 
  • Non blood stained 
No history of chest pain, palpitations, syncope. 
No history of oliguria. 
No history of Haemoptysis. 


He is a known case of hypertension since 5 years and is a chronic alcoholic and smoker since 18 years of age. 




General examination

Patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 
He is well oriented to time, place, date and person. 

Pallor: present 
Icterus: absent
Cyanosis: absent 
Clubbing: absent 
Koilonychia: absent 
Lymphadenopathy: absent 
Edema: present 




Vitals 

Temperature: afebrile

Pulse rate: 92bpm, regular in rhythm, normal in character and volume. No radio radial or radio femoral delay. 

Respiratory rate: 18 cycles/minute 

Blood pressure: 180/90 mm Hg. Measured in right arm and in supine position. 
SpO2: 98%

Cardiovascular System

Jugular Venous Pressure is elevated.


Apex beat is tapping type and well localized at 5th inter coastal space. 




Respiratory system 

Tachypnea present. 

Investigations 
1. Hemogram 


2. Renal function test 



3) ECG


4) Chest X Ray


Treatment received by the patient: 

Injection Lasix- loop diuretic 

Tablet Nicardia- calcium channel blocker

Injection Erythropoeitin 

Tablet Nodosis

Tablet Shelcal- Calcium supplement 

Tablet Orofex

Provisional diagnosis 

On the basis of his history and examination, I am of the opinion that he has Chronic Kidney Disease secondary to chronic Hypertension 

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