a 60 yr old with sob since 2 months
8/2/2023
Roll.no :51
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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 diagnosis and treatment plan "
A 60 YR OLD MAN WITH SOB SINCE 2 MONTHS
PATIENT CAME TO OPD WITH CHIEF COMPLAINTS OF :
- SHORTNESS OF BREATH SINCE 2 MONTHS
HOPI :
- patient was apparently asymptomatic 2 months back , when one night after having dinner with 30 ml alcohol , the patient had 4-5 episodes of vomiting in the morning , with food as content , non bilious , non projectile
- h/o fever the next day ,sudden onset , intermittent , high grade associated with chills and rigors , relieved on taking medication .
- h/o reduced appetite and 3 episodes of vomiting for the next 3 days
- the patient visited a local rmp and was put on iv fluids and used medication for vomitng and fever
-- h/o pain in right flank since 2 months
-- h / o shortness of breath grade 4 while lying down the next day for which he visted a local hospital , necessary investigations were done and patient was diagnosed with failure of two kidneys .
-- the patient then came to our hospital and hemodialysis was done . since he had less hemoglobin , blood transfusion was done during 1 st session and second session , dialysis was uneventful .
-- after 2 nd trasfusion , patient dveloped rashes and itching of skin all over the body , could be trasfusion reaction , and was advised to avoid transfusion , he is being given inj . erythropoetin
during 4 th session of dialysis , patient went hypotensive for which he was managed accordingly
- the patient underwent a total of 14 sessions of dialysis until now
-- h/o pain in right flank since 2 months
-- no h/o palpitations , chest pain , loose stools .
past history :
k/c/o htn since 3 yrs
k.c.o DM SINCE 3 YRS
PERSONAL HISTORY :
diet : mixed
appetite : reduced
bowel and bladder : regular
sleep : adquate but wakes up frequently to pass urine 4-5 times during night
addcitions : occasionally consumes alcohol
daily routine :
he is a farmer , wakes up at 4 am daily , goes to work by 5 am , has his breakfast at 9 am which is rice and curry , he has lunch again at 1 pm which is jowar roti . he returns back froom work by 6 pm and then watches tv and plays with kids
-- he has dinner around 8 pm which is rice with curry and goes to sleep
family history : insignificant
GENERAL EXAMINATION :
- Patient was examined after taking his consent
- Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished
- pallor present
- No signs of icterus , cyanosis , clubbing , oedema , lymphadenopathy .
His vitals:
Temperature : 98.3 F
BP : 120/80 mm HG
Pulse rate : 78 / min
Resp.rate : 16 cpm
GRBS : 167 mg/dl
Spo2 : 98 percent
systemic Examination:
CVS- S1 S2 heard,no murmurs present.
RS - bilateral Air entry present
Normal vesicular breath sounds heard
Per Abdomen :
inspection- normal scaphoid abdomen with no pulsations and scars
-- palpation - inspectory findings are confirmed
-- no organomegaly, non tender and soft
-- percussion- normal resonant note present, liver border normal
-- auscultation-bowel sounds heard, no bruit present
CNS :
CNS :higher mental functions : normal
Reflexes :
MOTOR-: normal tone and power
reflexes:
RT L T
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
INVESTIGATIONS :
DIAGNOSIS :
Chronic kidney disease on MHD
TREATMENT:
1) TAB. LASIX 40 MG PO /BD
2) TAB.NICARDIA 10 MG PO/TID
3) TAB.NODOSIS 500 MG PO/BD
4) TAB.SHELCAL 100 MG PO/OD
5) CAP BIO D 3 PO/OD
6) INJ.ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE AFTER HD
7) INJ.OROFER XT PO/OD
8) INJ.IRON SUCROSE 100 MG + 100 ML NS IV WEEKLY ONCE
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