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Name: G Sai Manogna
Roll no: 33
I've 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 a diagnosis and treatment plan.
Following is the view of my case :
CASE PRESENTATION:
A 56 year old male who is a resident of kattangur, Nalgonda has come to the OPD with the chief complaints of
- B/L pedal edema since 20 days
- Shortness of breath since 20 days
- Decreased urine output since 20 days
History of Presenting illness:
The patient was apparently asymptomatic 20 days ago, then he developed bilateral pedal edema (Pitting type) associated with shortness of breath (Grade-2 to Grade-3), decreased urine output and was taken to the hospital.
He was advised for dialysis but the patient was not willing
There were no aggrevating and relieving factors
No history of pain abdomen and loose stools
Past history:
Patient is a known case of hypertension since 6 months but is irregular while taking medication
Patient is not a known case of diabetes, asthma, TB
No history of blood transfusions
No history of any other surgeries
Personal history:
Diet- Mixed
Appetite-Good
Sleep- Adequate
Bowel movements- Regular
Micturition- Decreased urine output
Addictions- None
Allergic history:
No history of known allergies
Family history:
No significant family history
No family history of Hypertension, Diabetes, TB, Asthma
General Physical Examination:
Patient is conscious, coherent, cooperative
well oriented to time, place, and person
well nourished and moderately built
Pallor- Present
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Present
Vitals:
Temperature- Afebrile
Pulse rate- 99bpm
Respiratory rate- 18cpm
Blood pressure- 160/90 mm/Hg
SPO2- 99%
Systemic Examination:
CVS- S1 and S2 sounds are heard, No abnormal heart sounds
RS- Trachea is central, Dyspnoea present
CNS- No focal neurological deficits
Abdomen- Abdomen is soft, non tender
No organomegaly
Investigations:
CBP:
Blood grouping and RH type
Complete urine examination (CUE)
RFT
LFT
Urine protein/Creatinine ratio
HBsAg- Rapid
HIV Rapid test
Anti HCV antibodies- Rapid
SARS - COV-2 Qualitative PCR
ECG
Provisional Diagnosis:
Acute Kidney Injury which may proceed to Chronic kidney disease.
Currently on Dialysis
Treatment:
- Supportive treatment is given and patient is maintained on hemodialysis
- Salt restriction <2gm/day
- Fluid restriction<1.5 L/Day
Notes:
- The patient is advised to get dialysis done on a regular basis
- If any puffiness encountered, asked to come to hospital immediately
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