26 year old male with shortness of breath

 

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. 

 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 COMPLAINTS- 

This is the case of a 26 year-old male who came to the OPD with chief complaints of

  • Shortness of breath of since 10 days 
  • Bilateral pedal edema 
  • Decreased urine output since 10 days 
HISTORY OF PRESENT ILLNESS
The patient was apparently asymptomatic 10 days back. Then he developed shortness of breath which was associated with pedal edema and decreased urine output.

HISTORY OF PAST ILLNESS-

K/c/o Hypertension since 10 years 
The patient is not a known case of Diabetes, epilepsy, asthma, CAD 

PERSONAL HISTORY

•Mixed diet

•Loss of appetite

•Sleep adequate

•Bowel and Bladder movements regular.

TREATMENT HISTORY 

•k/c/o HTN since 10 years 
• Not k/c/o diabetes,CAD , asthma, TB.
•NO H/O chemo /radiation , blood transfusion.
•NO H/O previous surgeries.

FAMILY HISTORY 

Not significant.

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Cyanosis, clubbing, icterus, lymphadenopathy 

 •Pedal edema and Pallor present

VITALS
Temp: Afibrile
PR: 86bpm
BP: 130/90mm hg
RR: 22cpm

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

CVS: s1s2 heard
•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Breath sounds - vesicular

RS: BAE+ NVBS+

ABDOMEN
P/A: soft, non tender, bowels sounds heard

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

CNS: NFND

INVESTIGATIONS





 

PROVISIONAL DIAGNOSIS

 

CKD on MHD 

TREATMENT 


• Fluid restriction <1.5L/Day
• Salt restriction <2G/day

• TAB NICARDIA 10MG/PO/BD

• TAB LASIX 40MG/PO/BD

• TAB NODOSIS 550MG/PO/OD

• TAB SHELCAL 500MG/PO/OD

• TAB OROFER XT PO/OD

• INJ ERYTHROPOEITIN 4000IU weekly once 



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