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I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency and comprehending clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.
CHEIF COMPLAINTS:
.shortness of breath since 1 month.
. cough since 7 days.
. fever since 5 days.
.Bilateral pedal oedema since 5 days
HOPI:
Patients was apparently asymptomatic 1 month back then developed dyspnoea which was gradually progressive. patient was also feeling dyspneic while consuming food. patient was also feeling breathlessness after walking a short distance. he has grade 3 dyspnoea according to mmrc. Initially grade 2 then developed gradually. not associated with any palpitation and orthopnoea.
it was relived on resting and aggregated while doing work.
. patient also developed cough since 7 days(3.12.22) which was productive and intermittent in nature. patient told that he was coughing severely. initially started as dry cough then developed into productive cough.
he also had an episode of haemoptysis during this 7 days which was mild in nature.
. he also had fever which was of high grade and intermittent in nature since 5 days(5.12.22)
fever is of low grade associated with sweating mainly during the morning times. it is intermittent in nature which raises gradually during the evening times.
.patient also noticed bilateral pedal oedema which was putting in nature.
past history:
Patient is a known case of Hypertension since 10 years(2012) initially he was given medication but stopped after a few years since he was suffering from hypotension.
but since 3 years (2019)he again started taking metoprolol on advice from a local doctor after health-check up.
he is taking metoprolol 3 times a day.
patient not a known case of diabetes.
no history of TB, Asthama, epilepsy
SURGICAL HISTORY
Patient also has undergone nephrectomy procedure on the right kidney 10 years ago(2012) he was told that on checkup his kidney was bubbly and enlarged with cysts. has scars on the flanks(surgery)
patient had complaint of voiding of urine 5 months ago(july 2022), from then he was advised to undergo dialysis on day care basis.
PERSONAL HISTORY:
Mixed diet
Appetite - decreased
Regular bowl and irregular bladder movement
no allergies
no h/o alcohol and smoking
FAMILY HISTORY:
. not significant.
GENERAL EXAMINATION:
Patient is conscious coherent cooperative well oriented to time place and person
14.12.22.
BP: 190/100.
PULSE: 82 BPM normal rhythm and volume.
RESPIRATORY RATE: 30
TEMPERATURE: Afebrile.
PALLOR: PRESENT
Icterus - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - Bilateral pedal oedema since 5 days
Patient had again been followed up and vitals where checked on 17.12.22.
BLOOD PRESSURE:180/100
Temperate: afebrile
Respiratory rate: 33 cycles per min
Pulse:120 bpm
Systemic examination:
Respiratory system:
EXAMINATION OF CHEST:
INSPECTION:
SHAPE OF CHEST: NORMAL
TRACHEA POSITION CENTRAL.
apical impulse present at 4th intercoastal place.
movements of chest:
respiratory rate:30 cpm
skin over chest: no engorged vein, intercostal drainage scar present.
PALPATION
• All the inspectory findings are confirmed ,
• Trachea is in central position, no deviation
• Movements are decreased ( Rt > lft )
• Apex beat felt in Left 5th ICS , 1 cm lateral to the midclavicular line
• Vocal fremitus decreased in all areas of left side
PERCUSSION
• Dull note heard in all areas of left side
• Resonant heard in all other areas
AUSCULTATION
• Decreased air entry from left side
• Normal vesicular breath sounds +
• Breath sounds decreased in all auscultatory areas on left side .
CARDIOVASCULAR SYSTEM
INSPECTION
• Chest is Elliptical and bilaterally Symmetrical
• Trachea - Centre
• JVP - Normal
• Transverse diameter > Anterio posterior diameter.
• No scars and sinuses
PALPATION
• All the inspectory findings are confirmed ,
• Trachea is in centre
• Movements are decreased on left side
• Apex beat felt in Left 6 th ICS , 1 cm lateral to the midclavicular line .
AUSCULTATION
• S1S2 Heard
• No Murmurs
PER ABDOMEN
• Scaphoid
• No engorged veins , sinuses , scars
• No visible epigastric pulsations
• Soft and Tender +
• No organomegaly
• Tympanic note heard all over abdomen
• Bowel sounds +
CNS
• HMF - Intact
• Speech - Normal
• No signs of Meningeal irritation
• No Focal neural deficit
• Sensory and motor system - Normal
• Cranial nerve - Intact
• Reflexes - Normal
• Gait - Normal
• Cerebellum - Normal
PROVISIONAL DIAGNOSIS
AKI on CKD
Left sided pleural effusion
INVESTIGATIONS
GRBS
HBsAg
Blood Group
LEFT PLEURAL EFFUSION
Lights criteria
- Effusion protein/serum protein ratio greater than 0.5. 4.5/5.6 = 0.8
- Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6.
- Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH.
INFERENCE - Exudative pleural effusion.
POST ICD
TREATMENT:
Patient has undergone ICD since 14.12.22.
Patient has undergone two dialysis session since 13.12.22 to 16.12.22.
Patient has seen drop off in saturation levels and increase in blood pressure from 15.12.22(night)
16.12.22
He was sent for dialysis but still the levels where not improving so was supplemented with oxygen ventilation and also nitric oxide infusion.
PROVISIONAL DIAGNOSIS :
AKI on CKD
Left sided pleural effusion
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