60 y/o male with hypertension, heart failure and decreased urine output.

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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.


Patient was apparently asymptomatic 3 months ago, then he developed b/l pedal edema, initially extending only up to the ankles, which gradually progressed up to both the thighs, over the last 15 days.

Patient c/o decreased urine output since 15 days

c/o SOB Grade 2 , No aggravating or relieving factors.


History of Past Illness

K/C/O HTN since 6 months

N/K/C/O DM, EPILEPSY, THYROID DISORDERS.

NO H/O CAD, ASTHMA, TB

NO H/O PRIOR HOSPITALISATIONS, surgeries or blood transfusions.


Personal History

Married

farmer by occupation

Appetite- Normal

Non Vegetarian

Bowel movements- regular

Occasionally drinks Alcohol

Smoker

No h/o drug use


Family History:

No Significant Family history


PHYSICAL EXAMINATION

General Examination:

Patient is C/C/C

Thin Build, 

No pallor, icterus, cyanosis, edema, lymphadenopathy





VITALS:
Temp: 100 F

PR:98 bpm

RR:29 cpm
BP:

Lt arm:150/80 mm Hg

Rt arm:140/80 mm Hg

SpO2 : 84 % RA

GRBS: 124 mg/dl


SYSTEMIC EXAMINATION:

GIT:

Shape- Scaphoid

All quadrants of the abdomen are moving accordingly to respiration.

No tenderness, guarding.

On palpation, abdomen is soft, no hepatosplenomegaly.

Hernial orifices are normal.

No bruits

Bowel sounds are heard

Genitals- Normal.

 

CNS EXAMINATION:

Mental Status:

Patient was conscious, coherent ,cooperative. Well oriented to time, place and person.

 Language: Fluent, able to name relatives, follows commands 

Cranial Nerves- intact


Motor:

Upper Limb:

Pronator drift absent.



Tone:

Increased in both Upper and Lower limbs, asymmetrically.


Power:

Upper Limbs:3/5 in both limbs

Lower limbs: 2/5 in both limbs



Tremors:

Fine tremor present when arms are outstretched.




Posture:

On standing, patient is seen to be stooping.

Patient unable to walk by himself, needs support to stand and walk.


Finger to Nose Testing:

Normal


Rapid alternating Movements : Normal


Romberg: Negative


Proprioception:


Reflexes: Not able to elicit.

Babinski: Flexor response


Sensory Examination

Vibration: Normal

Joint position sense : Normal

Pin prick, temperature sensation: Normal


CVS:

S1, S2 Heard, No murmurs


RS:

Dyspnoea: Present

BAE present, NVBS heard

No adventitious sounds



INVESTIGATIONS:

HEMOGRAM
1/12/23


2/12/23


RFT:
1/12/23
2/12/23


ELECTROLYTES:
1/12/23:





ECG:

1/12







TREATMENT:

BLOOD TRANSFUSION DONE ON:

1/12/23 at 5:30 pm 
1 unit PRBCs



DIALYSIS DONE ON:
1/12/23 




 INJ. PIPTAZ 2.25 GM IV TID
INJ. LASIX 40 MG IV BD
INJ. NODOSIS 500 MG PO BD
TAB. ECOSPRIN-AV 75/10 O/HS
TAB MET-XL  25 MG PO/OD
TAB NICARDIA 10 MG PO/OD
TAB. DOLO 650 O]PO TID
TAB. SHELCAL CT PO OD
TAB. OROFER XT
INJ EPO 4000 U SC/ ONCE WEEKLY
INJ. IRON SUCROSE 200 MG IN 100 ML NS / WEEKLY ONCE

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