This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
DATE OF ADMISSION - 08/08/23
CHIEF COMPLAINTS
A 55yr old male patient resident of haliya came to general medicine opd with cheif complaints of SOB since 1week,dry cough since 3days,decreased urine output since 15days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently aymptomatic 6months back. Then he was on hemodialysis from6mnths back from june 2023.
Then he developed shortness of breath since 1week which is of grade 4 and insidious in onset and gradually progressive in nature which is aggrevated on talking and relieved on taking rest.
There is ARI with dry cough since 3days.
Bilateral pedal edema which is of pitting type is seen.
Decreased urine output since 15 days is seen.
HISTORY OF PAST ILLNESS
He is a k/c/o HTN sicne 6months
K/c/o DM since 20days
Is a k/c/o CKD since 2 and half yrs
Is k/c/o hypothyroidism from 1month.
TREATMENT HISTORY
k/c/o DM,HTN
Not a k/c/o CAD,TB,asthma,chemo,radiation.
Not a K/C/O blood transfusion (prbc-packed red blood cells).
PERSONAL HISTORY
Mixed diet
Appetite Lost
Sleep adequate
Bowel movements regular.
Micturition abnormal.
Habits-occasionally drinks alcohol
4-5 beedis perday.
FAMILY HISTORY
Not significant
PHYSICAL EXAMINATION
Temp-
BP-140/80 mm hg
Pulse rate-82/min
Respiratory rate-16/min
Spo2-
GRBS-
-No signs of pallor,cyanosis,lymphadenopathy,icterus.
-pedal edema present
SYSTEMIC EXAMINATION
•S1, S2 heard
RESPIRATORY SYSTEM:
•NVBS heard
•Position of trachea - central
•Breath sounds - vesicular
ABDOMEN
•Shape - obese
•No Tenderness
•No palpable mass
-No fluid present.
-No palpable liver or spleen
CENTRAL NERVOUS SYSTEM:
•Intact
•No focal defect
•No abnormality detected
CEREBRAL SIGNS
• No finger nose incordination
•No knee heel incordination.
INVESTIGATIONS
PROVISONAL DIAGNOSIS
CKD on MHD with k/c/o Hypertension and DM
K/c/o Hypothyroidism.
TRETMENT
1.Fluid restriction <5L per day
2.Salt restriction <2gms per day
3.T.lasix 20mg po/bd
4.Inj PAN IV /OD
5.Inj ZOFER IV/OD
6.Tab AMLONG 10mg po/bd
7.T NODOSIS 500mg po/bd
8. OROFER po/bd
9. INJ NEOMOL 1g IV
10. T DOLO 650 po/bd
11. INJ ERYTHROPOIETIN IV s/c twice weekly
12. Monitor vitals 4th hourly
13. Inform SOS
