A 55 YEAR OLD PATIENT WITH SHORTNESS OF BREATH AND DECREASED URINE OUTPUT.

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. 

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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 55 YEAR OLD PATIENT WITH SHORTNESS OF BREATH AND DECREASED URINE OUTPUT. 

A 55 year old male, farmer by occupation and a resident of rajammagudam, came with the chief complaints of 

• Shortness of breath since 1 year 
• Pedal edema since 3 days 
• Decreased urine output since 3 days. 

HISTORY OF PRESENTING ILLNESS 

• The patient was apparently assymptomatic 3 years back when he was diagnosed with diabetes when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication. 
• The patient was having blurring of vision and dizziness for which he went to the doctor and was diagnosed with hypertension and was given amlodipine. He is compliant with the medication. 
• The patient complains of shortness of breath since 1 year. It was initially of grade 2(MMRC Classification) that is he has to stop to take breath while walking at his own pace. For this he went to a local doctor and was given a tablet (unknown). 

• The shortness of breath has aggrevated to grade 4 MMRC classification that is shortness of breath even at rest 7 days back. 
• The shortness of breath was associated with PND and orthopnea. It was not associated with chest pain or palpitations. 
• The patient also complains of non productive cough since 3 days. 

• The patient has had decreased urine output for the past three days. In the 24hrs before admission he did not have any urine output. 

• He doesn’t have any hesitancy, increased frequency or fullness of bladder. 

PAST HISTORY 

He is not a known case of coronary artery diseases, Asthma, TB, epilepsy. 

PERSONAL HISTORY 

Diet: mixed

Appetite: decreased 

Bowel: normal 

Bladder : decreased urine output 

Sleep: disturbed 

Addictions: nil

Allergies (food/drugs) : nil 

GENERAL EXAMINATION 

•   The patient if conscious, coherent and cooperative 
• He is Moderately built and moderately nourished
• Pallor is present 
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• NO icterus, clubbing, cyanosis, generalised lymphadenopathy, pedal edema  is seen 

VITALS:

• PR: 62bpm
• BP: 110/80 mmHg
• RR: 20cpm
• Temperature: Afebrile

CVS: 

• On palpation:

-Apex beat was diffuse and was felt at 6th intercostal space lateral as well as medial to mid-clavicular line. 

-JVP was raised 

-No precordial bulge 

-No parasternal heave

-On auscultation, S1, S2 heard; no murmurs were heard 

RESPIRATORY EXAMINATION: 

• INSPECTION:  bilaterally symmetrical 

-Expansion of chest: Equal on both sides

-Position of trachea: Central

-Supraclavicular and infraclavicular hollowness was not seen 

-No Crowding of ribs 

-No visible scars, sinuses, pulsations

• PALPATION:

-expansion of chest was equal on both sides. 

-Position of trachea: Central

-Vocal fremitus: resonant note was felt.

• PERCUSSION: all lung areas were resonant 
• AUSCULTATION:

-Bilateral air entry was present. Vesicular breath sounds were heard.  
-Vocal resonance: resonant in all areas

PER ABDOMINAL EXAMINATION 

• Soft, non-tender
• No hepato-spleenomegaly was noted

CNS : intact 

On 19/02/22 : the patient was admitted and dialysis was done. (Indication: metabolic acidosis pH: 7.19) 

On 20/02/22 : the patient had another session of dialysis. (Indication: metabolic acidosis pH: 7.29)