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
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