MEDICINE CASE DISCUSSION
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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
PAVITRA BALDAWA
ROLL NUMBER -104
30th October 2021
CASE DISCUSSION
A 44 year old male patient who is a farmer by occupation and a resident of nalgonda came to the medicine OPD on 28/10/21
Chief complaint:
Shortness of breath since 1 week
Bilateral pedal edema since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 7 days back
SHORTNESS OF BREATH:
Onset- insidious
Duration-7 days
Progression-gradual
Aggravating factors- walking
Grade 3 (according to mmrc)
Not associated with orthopnea or paroxysmal nocturnal dyspnea)
Associated with chest pain since 7 days which was contionous and increased on inspiration
Not radiating to shoulder or back
Associated with fever since 7 days which reduced on medication
Not associated with cold ,cough,chills or rigor
PEDAL EDEMA
Onset : insidious
Progression- gradual
Type-pitting
Bilateral
No aggravating relieving factors
Past history:
No similar complains in the past
Diagnosed with- Diabetes mellitus-5 years - on glimerperide-1mg
Hypertension-15 yrs- telmesartan and Amlodipine
Chronic kidney disease-11yrs
Went to the local hospital with the complain of fever and tiredness
After examination he was diagnosed with CKD
and is on medication for the same
5 years ago he had pedal edema and SOB for which he took diuretics and it reduced
No history of surgeries and no history of dialysis
Personal history-
Diet- mixed
Appetite- reduced
Sleep- adequate
Bowel and bladder-regular
Addictions-
Alcohol- 1 quater per day until 6 years ago
Beedi 10 per day since teenage
Stopped 10 years ago
Family history- insignificant
General examination-
Patient was conscious coherent and cooperative
Moderately built and nourished
Well orientated to time place and person
Pallor- present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema - bilateral pedal edema
Vitals-
Pulse rate-86bpm
Blood pressure- 120/80 mmhg
Respiratory rate- 22 cpm
Temperature- afebrile
Systemic examination
Cardiovascular system:
S1 and S2
No murmur
Apex beat 6th intercoastal space lateral and outward
Jvp- raised
Epigastic pulsations present
Respiratory system:
Normal breath sounds
Per abdomen:
Solf non tender
Truncal obesity
Central nervous system:
All high motor functions intact
sensory system normal
Investigations:
Blood urea-102 mg/dl
Sodium-122mEq/L
Chloride-34mEq/L
Serum creatinine- 3.4 mg/dl
ECG
Hepatitis B antigen
USG REPORT
Chest X-ray
Provisional diagnosis:
HEART FAILURE with PRESERVED EJECTION FRACTION with EF -55% WITH CKD SINCE 10 YEARS STAGE -IIIB with DM since 5 YEARS with HTN since 15 YEARS
Treatment:
SALT RESTRICTION < 2.4 GM/DAY
FLUID RESTRICTION< 1 LT/DAY
INJ LASIX 40MG /IV/BD ( IF BP>110MHG)
INJ PANTOP 40 MG /IV/OD
TAB. NODOSIS 550 MG /PO/OD
TAB. SHELCAL 500MG /PO/OD
TAB PCM 500MG /PO/SOS
INJ. PIPTAZ 2.25 G/IV/BD(DAY 1)
INJ. NEOMOL 100 ML /IV/SOS
MONITOR VITALS HOURLY
STRICT I/O CHARTING
INJ HAI PRE MEAL S/C 8AM-2PM-8PM
GRBS MONITORING
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