A 55YEAR OLD MALE WITH ANASARCA and SOB.
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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.
A 55 year old male came to the casuality with the chief complaints of pedal edema since 6 days and facial puffiness since 4 days. He also complained of shortness of breath, decreased urine output,decreased vision and decreased appetite since two days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic six days ago when he developed facial puffiness which was sudden in onset and was gradually progressive.
Patient also developed pedal edema of pitting type ,2 years ago which was insidious in onset and was persistent ,but gradually progressed to the present state six days ago.
Patient also complains of SOB which was insidious in onset, gradually progressed from grade 2 to grade 3 NYHA.
No history of orthopnoea and PND.
PAST HISTORY:
Patient has a history of right sided hemiparesis secondary to CVA. It was treated conservatively with antiplatelet drugs which he was using on and off. He was able to walk after the treatment.
He is also a k/c/o Hypertension since 1 1/2 year for which he is on regular medication ( Tab. Met XL )
He is also a k/c/o Diabetes since three years for which he's on Human Actrapid 15U--×--8U.
He is also a k/c/ o CKD 1 year ago for which he was managed conservatively and was not on hemodialysis.
He is also a k/ c/ o CAD since one year.
Not a k/c/o TB, Asthma ,epilepsy.
PERSONAL HISTORY:
Apetite: decreased
Diet: mixed
Sleep: Inadequate
Urine output: decreased
Constipation is present(once in 8 to 10 days with medication)
Addictions: Patient was an alcoholic. Stopped alcohol 2 years ago.
No known allergies.
PHYSICAL EXAMINATION:
General examination
Consent was taken. Patient was examined in well-lit room. Patient has altered sensorium.
He is afebrile.
BP :
Pulse rate : 76 bpm
Respiratory rate:
SpO2: 98%
He has pallor.
Edema : present ( Anasarca)
Icterus, Clubbing, Cyanosis, Kolionychia Lymphadenopathy - absent.
SYSTEMIC EXAMINATION
CVS : S1 S2 heard (muffled)
Diffuse apex beat.
No murmurs or thrills heard.
Respiratory system :
BAE+ , decreased B/L breath sounds.
B/L Crepts were heard.
Dyspnoea of grade III
PER ABDOMEN:
Distended, Soft, non tender
Free fluid +
Scrotal swelling is present.
CNS:
No abnormalities detected.
Nov 15,2021
General examination
Afebri
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