A 37 year old male with shortness of breathe and pedal oedema

 


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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.




A 37yr old male patient ,resident of indrapal nagar a construction site worker by occupation presented to our hospital with cheif complaints of:

Shortness of breath since 1month

Pedal edema since 1 month 


HOPI: patient was apparently asymptomatic 4 months back.then he developed shortness of breath which lasted for about 2 days and relived on medication. 

H/o burning micturition and passing of foamy urine.

During this time pt also presented with high BP due to irregular treatment.he was also diagnosed to have renal failure and kidney problems . 

One month back he developed similar complaints of SOB (grade 3) ,pedal edema (pitting type), decreased appetite,fever which was intermittent and lasted for about 20days , bodypains,weakness,disturbed sleep (due to aggrevation of SOB in supine posture).



PAST HISTORY: 

Known case of HTN Since 2 yrs 

No H/O DM,TB,asthma,epilepsy, thyroid diseases 


PERSONAL HISTORY:

Diet-mixed 

Appetite- decreased 

Sleep -disturbed 

Bowel nd bladder- regular 

Addictions - 

Smoking since 15 yrs 

Tobacco chewing since 15yrs

Alcohol since 15 yrs.

 

GENERAL EXAMINATION: 

Pt was consious, coherent, cooperative and well oriented to time place and person

Moderately built 

Pallor -

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal edema +

Lipomas seen over hands and abdomen .


Vitals:

Temperature: afebrile 

PR: 80/min

RR:17 cpm

BP:140/90


SYSTEMIC EXAMINATION:

CVS: 


Inspection: 

Chest wall shape- barrel shaped 

Scars,sinuses,- absent

Dilated veins- not seen 

Apex beat- can be seen in 6th ICS 1.5cm  lateral to midclavicular line.

JVP- raised



Palpation: 

All the above inspection findings are confirmed by palpation.

Apex beat- can be palpated in 6th ICS 1.5cm lateral to midclavicular line.

Parasternal heave- grade 3


Auscultation:

S1,S2 heard 


Respiratory system:

NVBS heard 

P/A:

Abdomen is soft non tender 

Few lipomas can be seen over abdomen

CNS: no focal neurological deficits 


PROVISIONAL DIAGNOSIS:

Chronic renal failure secondary to hypertensive nephropathy.? RAS?

RPGN?















JVP




INVESTIGATIONS





USG
DOPPLER


 
USG

X-RAY

ECG                                                                    


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