Case: 47 yr old with anasarca and oliguria
Neha Pradeep, MBBS 9th semester
Ratio: 6.10
Roll no: 99
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. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
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 diagnosis and treatment plan.
Case:
47 year old male patient with bilateral pedal edema, puffiness of the face and breathlessness.
History of Present Illness:
Patient was apparently asymptomatic 6 days ago, when he developed swelling of both legs uptil the knees and the next morning he developed facial puffiness.
The swellings have progressed since 3 days. The swelling has slowly progressed to the entire body.
Patient has shortness of breath since 6 days. It was sudden in onset and progressed from Grade 2 to Grade 4, which aggrevated on lying down.
There has been a decrease in urine output since 3 days.
Once the patient noticed the leg swelling 6 days ago, he ignored it and went through his normal day, the next morning he noticed facial puffiness and went to the local RMP. The doctor referred him to a specialist, who told him he had fluid around his kidneys and heart. He gave him medication for 10 days, which then worsened in 3 days. He then came to Kamineni Hospitals.
Patient also has a decreased appetite.
Patient has no history of fever, cough, cold, chest pain, vomiting, diarrhoea, giddiness, palpitations or burning micturition.
Past History:
Patient has a history of hypertension since 8 years, diabetes mellitus since 6 years. He takes medication regularly for both.
He takes Tab Mili BD
5 years ago, he was admitted in the hospital due do to acute pancreatitis.
No history of tuberculosis or asthma.
Personal History:
Diet: Mixed
Appetite: Decreased since 6 days
Sleep: Decreased since 6 days
Bowel and Bladder: No urine output since 3 days
Allergies: None
He stopped drinking alcohol 5 years ago after drinking for 15 years.
He smoked 1 pack a day for 15 years, and stopped 5 years ago.
General Examination:
Patient is conscious, cooperative and coherent.
Moderately built and moderately nourished.
Pallor: None
Icterus: None
Clubbing: None
Cyanosis: None
Lymphadenopathy: None
Edema: Bilateral Pitting Edema
Vitals:
Temperature: Afebrile
Pulse Rate: 76 BPM
BP: 116/80 mmHg
Respiratory Rate: 16 cycles per minute
CVS:
Inspection:
No visible scars, sinuses, engorged veins, visible pulses, precordial bulge.
No visible apical impulse.
Palpation:
Apical Impulse: on midclavicular line, 5th intercostal space
No tenderness and no local rise in temperature
No murmurs and no pulsations felt.
Percussion:
Heart Borders:
Medial Border: on sternum at level of 4th intercoastal space
Lateral Border: Below the left nipple.
Auscultation:
S1 and S2 heard
No murmurs
CNS:
No focal neurological deficit.
All higher motor functions are normal.
RESPIRATORY SYSTEM:
BAE
Normal vesicular breath sounds heard
ABDOMINAL EXAM:
Distended abdomen
Everted Umblicus
Non tender
Liver and spleen not palpable
LAB TESTS:
CUE:
Albumin: ++++
Pus Cells: 4-6
Epithelial cells: 2-4
RBCs, Casts, Crystals: Nil
LFT:
Tb: 1.12
AST: 14
ALP: 304
TP: 5.6
Alb: 3.1
A/G: 1.28
ECG:
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