A 60 year old male patient with CKD and sob
This E blog also reflects my patient cantered 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.
Case presentation :
A 60 year old male patient resident at suryapet with daily labour on occupation Came to opd with
Chief complaints :
-bilateral pedal edema since 2 months
- decrease urine output since 2 month
- breathlessness since 10 days
History of presenting illness :
Patient was apparently asymptomatic 2 months back then he developed bilateral pedal edema , insidious in onset , gradually progressive , which is pitting type and extended Upto knee. Aggravated on walking and physical activity , relieved after dialysis.
Then later he developed decrease in urine output which is more in frequency but less in quantity (10-15 ml ) h/o nocturia ( 4 times during night )
He recently developed shortness of breath 10 days back which is insidious in onset , gradually progressive , initiated with grade 1 then progressed to grade 4 ( even on rest ) aggravated on walking , physical activity and relieved on rest
No h/o orthopnoea , chest pain , pnd
No h/o fever , vomitings , cough
No h/o palpitations , sweating
No h/o headache , sleep disturbances
No h/o heamturia
Past history :
No similar complaints in the past
K/c/o diabetes since 6 years (Glimi-m1)
K/c/o hypertension since 3 years ( t - amlokind - 80 )
No h/o epilepsy , tuberculosis , asthma
He underwent fistulectomy 5 years ago
Personal history :
Mixed diet
Adequate sleep
Regular bowel movements
Decrease urine output
He stopped alcohol 1 year ago
No smoking
No allergies
Family history :
Not significant
General examination:
Patient was coherent , conscious , cooperate
Moderately built , moderately nourished
No signs of pallor , icterus , clubbing , kolinychia , lymphadenopathy
Vitals :
Temperature - afebrile
Heart rate - 80 bpm
Bp - 120/80 mmhg
Rr - 16 cpm
Systemic examination :
Respiratory
Inspection -
Trachea appears to Be central
Shape of chest appears to elliptical
Chest movements appears to Be equal on both sides
No drooping of shoulder , spine deformities
No scars , sinuses , swellings , engorged veins
No hallowing
No crowding of ribs
Apical impulse is seen
Palpation :
All inspection findings is confirmed
Trachea is midline
No local rise of temperature
No tenderness
Apical impulse in felt
Bilateral chest movements are equal
No swellings , mass are felt
Vocal fermitus - normal
Percussion :
Bilateral resonant
Auscultation :
Bilateral vesicular breath sounds are heard
Central nervous system -
No focal deficits
Per abdomen :
Non tender , soft
Cardiovascular system :
S1, s2 heard ; no murmurs
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