45 yr old male,toddy climber 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 ,toddy climber by occupation came to the opd with cheif complaints of
Sob since 1 month
Fever since 15 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 10 months ago Later he developed multiple episodes of fever -insidious in onset , low grade continuous fever ,not associated with chills and rigors, relieved on medication (tab.paracetamol),later 9 months ago he developed shortness of breath grade 4 which was gradual in onset,progressive in nature,associated with orthopnea and pnd for which he went to the hospital and was told he was anemic and has a kidney problem (high creatinine levels - value 17.9 ,urea 239 ).he underwent a session of dialysis and his levels were normal and returned back home
1 month back he developed sob since which was gradual in onset ,progressive in nature associated with orthopnea and pnd he also developed fever - insidious in onset , low grade continuous fever ,not associated with chills and rigors, relieved on medication (urea - 468,creatinine - 25.9) for which he was started on dialysis and underwent 3 sessions so far .
PAST HISTORY :
No history of similar complaints in the past
Not a k/c/o of hypertension , diabetes ,tb, epilepsy,asthma,cad
No history of any surgeries
History of blood transfusions on 7/8/21 and 8/8/21
PERSONAL HISTORY :
Married for 24 years and has 2 children
Sleep : adequate
Appetite : decreased since 1 month
Bowel and bladder movements : regular
Alcohol and tobacco consumption:
History of alcoholic consumption since 20 years ,drinks 90 ml whisky daily ,stopped 1 month back.
No history of tobacco consumption
Daily routine - wakes up in the morning completes his daily chores and goes for toddy climbing, comes back in the evening, drinks alcohol and has his dinner and goes back to bed.Complaints of frequent episodes of fever and body pains for which he visits local doctor and takes medication
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.
Pallor present
No signs of icterus ,koilonychia,cyanosis , lymphadenopathy,pedal edema
Pulse = 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay.
- Blood pressure = 110/70 mm of Hg measured in sitting position
- Respiratory rate = 26 cycles per minute
Temperature : Afebrile
CVS Examination
S1 and S2 heard , No murmurs heard
Respiratory system examination
Normal Vesicular Breath sounds heard,fine crepts heard in right infra axillary area.
No added sounds
Abdominal examination
Inspection-
Shape : elliptical
Umbilicus - central and inverted
No scars,sinuses or engorged veins
Palpation:
No tenderness , No organomegaly
CNS Examination :
Higher mental functions-normal
Cranial nerves- intact
Sensory system- normal
Motor system- normal
Meningeal signs- absent
Cerebellar signs- absent
Investigations :
On 7/8/21
Blood transfusion was done (1 PRBC)
ON 8/8/21
ON 9/8/21 :
TREATMENT :
On day 1 of admission :
Fluid restriction<1.5L/day
Salt restriction <4 gm /day
Inj.monocef 1gm IV /BD
Inj.pan 40 mg IV /OD
Inj.lasix 40 mg IV/BD
Tab.nodosis 1gm PO/BD
Tab.orofer xt PO/BD
Tab.shelcal ct PO/OD
Inj.erythropoietin 4000 IU S/C weekly twice
Strict I/O monitoring
BP,PR,TEMPERTURE,Sp02 monitoring 4rth hrly
On day 2 of admission :
Same as day 1
On day 3 of admission :
Same as day 2
