general medicine final practical exam-short case

65Y/M PATIENT WITH COMPLAINT OF SOB AND DISTENSION OF ABDOMIN AND PEDAL EDEMA

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 a diagnosis and treatment plan.

 CHIEF COMPLAINT:

A 65 years old male patient ,resident of suryapet ,mason by occupation,came to the casualty with chief complaint of shortness of breath since 5 days
Distension of abdomen and pedal edema since 1 week.

HISTORY OF PRESENT ILLNESS:
->patient was apparently asymptomatic 1year back then she has  shortness of breath, pedal edema, distension of abdomen.She went to a local hospital and was diagnosed with renal failure and heart failure.

7 months back  patient had similar episodes and had Hb of 6 approx and 20 prbc and transfusion was done
diagnosed as anemia secondary to CKD 
NO H/O of hematemesis, decreased apetite 

->1 week back- 
shortness of breath which is insidious in onset,
orthopnea+ 
no h/o PND, no h/o wheezing 
chest pain occasionally present which is radiating to arms, relieved after taking medication. 
distension of abdomen- 2 months
decreased urine output, appetite is normal, burning micturition, pedal edema since 3 months, piiting type and increased while standing also.

HISTORY OF PAST ILLNESS:
Not a k/c/o TB, asthma, epilepsy 
History of diabetes mellitus

FAMILY HISTORY:
no relevant family history

PERSONAL HISTORY:

Appetite:Normal
Diet:Mixed
Bowel and bladder : Regular
Addiction: patient have an habit of smoking since 30years ( 1 pack per day)
Marital status: married
Occupation:Mason
Sleep: inadequate

GENERAL EXAMINATION:
-Patient is conscious, coherent and cooperative.
-Well oriented to time, place and person.
-Moderately built and well nourished.
-Pallor: yes
-Icterus: no
-Cyanosis: no
-Clubbing of fingers: no
-Lymphadenopathy: no
-Pedal oedema: yes 

VITALS: 
-Temp: afebrile
-BP: 150/90mmHg 
-PR: 76bpm
-RR: 16 cpm
-SpO2: 100
SYSTEMIC EXAMINATION:

CNS examination:
Memory intact
-Speech is normal.
-no abnormality detected

CVS examination:

-S1, S2 are heard.
-No murmurs

Respiratory examination:
INSPECTION:

Size and shape: bilaterally symmetrical and elliptical 

Position of Trachea: central

No supraclavicular hollowing

PALPATION:

Trachea:midline 

Position of apical beat at 5th intercostal space , 1 inch medial to midclavicular line.

PERCUSSION:

 Dull sound on percussion

AUSCULTATION:

dyspnoea - present
wheeze- present

Abdomen:
Inspection:
Shape of Abdomen is Distended
Surface shows No Dilated veins, engorged veins, scars.

Palpation:
Liver and spleen not palpable 

Percussion:
Resonant note is heard


Investigation:

 

Provisional diagnosis:
- CKD secondary to diabetic nephropathy

TREATMENT:
Tab Lasix 40mg
Tab Nodosis 500mg
Tab Orofer
Cap BIOD3
Tab Shelcal
Tab Nicardia 10mg
Tab Carvidilol

Monitor vitals
 




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