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 diagnosis with a treatment plan.
Hall ticket number: 1601006172
This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.
Short Case
A 55 year old gentleman hailing from Miryalaguda, laborer by occupation came with
Chief complaints:
Difficulty in breathing since 4 days.
History of present illness:
He was apparently asymptomatic 4 months back.
1. Then he developed fever, which was:
- Insidious in onset
- Intermittent
- Non progressive
- Low grade
- Not associated with chills or rigors
- No diurnal variation
- Relieved by medication briefly
As the fever wasn’t subsiding, he went to Miryalaguda hospital where he was diagnosed with Chronic Kidney Disease and was prescribed medication for the same.
2. 2 months back, he developed Bilateral pitting edema, which was initially limited to ankles (grade II) and then progressed till the knees (grade II)
3. 4 days back, he developed dyspnoea on 21st April around 2 AM in the night.
- Sudden in onset
- Grade: IV
- Postural variation: present (increased on lying down)
4. 3 days back he developed cough which was sudden in onset
- Sudden in onset
- Dry in nature
- Non blood stained
No history of chest pain, palpitations, syncope.
No history of oliguria.
No history of Haemoptysis.
He is a known case of hypertension since 5 years and is a chronic alcoholic and smoker since 18 years of age.
General examination
Patient is conscious, coherent and cooperative. He is moderately built and moderately nourished.
He is well oriented to time, place, date and person.
Pallor: present
Icterus: absent
Cyanosis: absent
Clubbing: absent
Koilonychia: absent
Lymphadenopathy: absent
Edema: present
Vitals
Temperature: afebrile
Pulse rate: 92bpm, regular in rhythm, normal in character and volume. No radio radial or radio femoral delay.
Respiratory rate: 18 cycles/minute
Blood pressure: 180/90 mm Hg. Measured in right arm and in supine position.
SpO2: 98%
Cardiovascular System
Jugular Venous Pressure is elevated.
Apex beat is tapping type and well localized at 5th inter coastal space.
Respiratory system
Hyperpnea present.
Investigations
1. Hemogram
2. Renal function test
Treatment received by the patient:
Injection Lasix- loop diuretic
Tablet Nicardia- calcium channel blocker
Injection Erythropoeitin
Tablet Nodosis- Antacid
Tablet Shelcal- Calcium supplement
Tablet Orofex
He is currently undergoing dialysis.
Provisional diagnosis
On the basis of his history and examination, I am of the opinion that he has Chronic Kidney Disease secondary to chronic Hypertension
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