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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 in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.
AMC BED
DOA:21/424
65 year old male ,farmer by occupation came to the opd on 21/3/24 with c/o
SHORTNESS OF BREATH since 15 days (on and off)
Pedal oedema since 15 days
History of present illness;
He was apparently asymptomatic 15days back then he noticed swelling of both limbs ,insidious in onset ,gradually progressive(extending from ankle to knee), no aggravating and relieving factors.
SOB SINCE 15 days ,insidious in onset ,gradually progressive (grade 2 to grade 4),aggravating on lying down relieving on sitting .
Associated with orthopnea and PND
Not associated with chest pain ,cough ,fever and palpitations.
Past history:
K/c/o HTN since 10years (on regular medication Nicardia 20mg )
K/c/o DM since 6 years (on regular medication initially OHAS for 4 years followed by INSULIN since 2 years )
Not a k/c/o epilepsy ,TB,asthma ,CAD.
Personal history:
Diet :mixed
Appetite :normal
Bowel and bladder - regular
Sleep - disturbed due to SOB
No known allergies
No addictions
Family history:insignificant
General examination:
Patient is conscious,coherent and cooperative And well oriented to time ,place and person.
Vitals ;
Temp:97.4F
PR:96bpm
RR:23cpm
Bp:140/90mmofhg
Spo2:96%
GRBS:100mg/dl
Pallor +
No icterus ,clubbing ,cyansosis ,lymphadenopathy
Pedal oedema+
Systemic examination:
RS: BAE+; NVBS+
CVS:s1,s2 heard ,no murmur heard
CNS:NFND
P/A:soft,non tender ,no organomegaly
Provisional diagnosis:
CKD on MHD
HEART FAILURE with MID RANGE EJECTION FRACTION .
Investigatons: on1/4/23
BGT: O positive
Hemogram:
Hb-8.1gm/dl
Tc:7800cells/Cumm
N/L/E/M:79/11/2/8
PCV:26.8vol%
MCV:100.1fl
MCH: 31.2pg
MCHC:30.2%
RDW-CV:14.7%
RDW-SD:55.5fl
RBC:2.60millions/cumm
PLT:2.80lakhs/cumm
Smear:NCNC
CUE:
Sp .gravity:1.010
Albumin: +++
Sugar :++++
PC:4-5/HPF
EC:2-3/HPF
RBC:nil
Crystal:nil
Casts :nil
RBS: 177mg/dl
RFT :
Urea:40mg/dl
Creatinine:4.8mg/dl
UA:3.6mg/dl
Calcium:10.0mg/dl
Phophorous :2.9mg/dl
Na+:144mEq/L
K+:4.3mEq/L
Chloride :105mEq/L
LFT:
TB:0.71mg/dl
DB:0.18mg/dl
SGOT:15IU/L
SGPT:12IU/L
ALP:224IU/L
TP:6.5gm/dl
Alb:3.3gm/dl
A/G ratio:1.01
Serology:Negative
On 2/4/24:
ABG:
PH: 7.18
Pco2:51.0mmhg
Po2:107mmhg
Hco3:18.7mmol/L
St.Hco3:17.2mmol/L
Troponin -I: 34.9pg/ml —-> 30.0(as on 21/4/23)
On3/4/23:
RFT:
ABG:
PH: 7.34
Pco2:39.70mmhg
Po2:178mmhg
Hco3:21.2mmol/L
St.Hco3:21.4mmol/L
On 22/4/24:
Hemogram:
ECG
On 21/4/23:
On 22/4/23:
2decho: on 21/4/23
USG ABDOMEN on 1/423:
2/4/24:
Treatment :
Underwent 7 sittings of dailysis till date .
1)Tab.furosemide 40mg /po/Bd
2)Tab.nifedipine 20mg/po/TID
3)Tab.clonidine0.1mg/po/Bd
4)Tab.atorvastatin and aspirin (75/10)/po/HS
5)Tab.sodium bicarbonate 500mg/po/BD
6)Tab.Ferrous ascorbate and folic acid/po/OD
7)cap.calcitriol and calcium po/OD
8)Inj.erythropoietin 4000U /SC/weekly once
9)Inj.Human actrapid insulin sc/TID acc to RBS
10)Bp/temp/PR/RR monitoring 4th hrly
