Gm final long case

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

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. 

55 Yr old male, granite cutter by occupation presented to casualty due to swelling of both the feet.

CHIEF COMPLAINTS:

Swelling of both the feet and shortness of breath from past 2 months.

History of present illness:

 Patient was asymptomatic 3 months back then he developed wet cough. ( on and off type) 
2 months back he developed shortness of breath while doing work. 
It was aggravated by work and not relieved by medication
He also had pedal edema( non pitting type) and puffiness of face since 2 months. 
No history of blood vomiting, no history of fever.

Past history: 

He got his right eye hit by a hard stone due to which he lost his  right eye vision permanently. 

He's not a known case of TB/ DM / ASTHMA / epilepsy. 

Personal history: 

Mixed diet 

-Reduced appetite 

Adequate sleep

-Irregular bowel movements 

-Consumes Alcohol and tobacco from past 30 years. 

-Patient has Burning micturition. 

Family history : 

No relevant family history. 

General physical examination:

Pallor - present 

Cyanosis- absent 

Icterus- absent

Lymphadenopathy: absent

Oedema: Non pitting type

Bilateral edema.

VITALS: 

Temperature- Afebrile

Pulse rate- 72 beats per minute.

Respiratory rate- 20 breaths per minute. 

B.P - 140/70 mm hg

Spo2 - 99% at room air

Systemic examination: 

CVS:- S1 and S2 are heard,NO MURMUR

RS:- BAE+ , NVBS+

P/A SOFT ,NT

CNS: 

Pt. was conscious, coherent and co-operative.  

Speech was normal. No slurred speech. 

No meningeal signs.

- No abnormality detected. 

Reflexes:

Right and left biceps, triceps, ankle and supinator show grade 2 reflex.

Gait: 

Normal.

INVESTIGATIONS:

1. Colour doppler 2D echo: 

2. Complete urine examination:

3. Ultrasound report: 

       

6. Renal function tests:

7. Liver function test: 

8. ECG 

PROVISIONAL DIAGNOSIS:

Polycystic kidney disease, Chronic kidney disease

Treatment: 

Fluid and salt restriction.

T. Nodosis 500 mg BD 

T. Orofer xt PO BD 

Inject erythropoetin 4000 IU weekly once

T. Shelcal PO OD

Inject thiamine 100 mg in 50 ml NS  I.V / TID 

T. Nicardia 20mg BD