45 yr old male ,farmer by occupation
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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.
CASE :
A 45 yr old male ,farmer by occupation came to the opd with chief complaints of
Pedal edema since 1 month and
Shortness of breath since 1 month
HISTORY OF PRESENT ILLNESS :
Pt was apparently asymptomatic 2 years ago later he developed giddiness, fatigue since few days for which he went to hospital,was diagnosed as hypertensive and advised to take clinidipine 20 mg in the morning and 10 mg in the night
Later 1 and half year ago he consulted a doctor for generalised weakness and fatigue , and underwent some investigations in which his creatinine was 4 and was advised to take medication to reduce creatinine levels for about an year(unknown medication).pt used this medication only for 6 months and then stopped the medication.
Later 3 months ago he was diagnosed as covid positive for symptoms of fever ,cough and cold.He recovered from covid by home isolation without using any medication within 20 days
Later he developed shortness of breath and pedal edema since 1 month.
Pedal edema which is gradual in onset,progressive in nature ,pitting type upto knee .
SOB since 1 month - grade 2 dyspnea ,6 episodes of pnd,not associated with orthopnea
PAST HISTORY :
No history of similar complaints in the past
Not a k/c/o of diabetes ,tb, epilepsy,asthma
No history of any surgeries or blood transfusions in the past
PERSONAL HISTORY :
Married for 26 years and has 2 children
Sleep : adequate
Appetite : decreased since diagnosed as hypertensive,stopped taking non veg food since 1 year
Bowel and bladder movements : regular
Alcohol and tobacco consumption:
History of alcoholic consumption10 years ago ,occasional drinker weekly thrice,stopped 3 months back.
No history of tobacco consumption
FAMILY HISTORY :
No significant family history
CONSENT OBTAINED
General physical examination:
The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
Pedal edema is noticed which is of pitting type progressive in nature,extending up to the knees
Pallor present
No signs of icterus ,koilonychia,cyanosis , lymphadenopathy
Pulse = 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay.
- Blood pressure = 160/100 mm of Hg measured in sitting position
- Respiratory rate = 24 cycles per minute
- raised jvp
