60 y/o male with hypertension, heart failure and decreased urine output

 

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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.

Patient was apparently asymptomatic 3 months ago, then he developed b/l pedal edema, initially extending only up to the ankles, which gradually progressed up to both the thighs, over the last 15 days.

Patient c/o decreased urine output since 15 days

c/o SOB Grade 2 , No aggravating or relieving factors.

History of Past Illness

K/C/O HTN since 6 months

N/K/C/O DM, EPILEPSY, THYROID DISORDERS.

NO H/O CAD, ASTHMA, TB

NO H/O PRIOR HOSPITALISATIONS, surgeries or blood transfusions.

Personal History

Married

farmer by occupation

Appetite- Normal

Non Vegetarian

Bowel movements- regular

Occasionally drinks Alcohol

Smoker

No h/o drug use

Family History:

No Significant Family history

PHYSICAL EXAMINATION

General Examination:

Patient is C/C/C

Thin Build, 

No pallor, icterus, cyanosis, edema, lymphadenopathy

VITALS:

Temp: 100 F

PR:98 bpm

RR:29 cpm

BP:

Lt arm:150/80 mm Hg

Rt arm:140/80 mm Hg

SpO2 : 84 % RA

GRBS: 124 mg/dl

SYSTEMIC EXAMINATION:

GIT:

Shape- Scaphoid

All quadrants of the abdomen are moving accordingly to respiration.

No tenderness, guarding.

On palpation, abdomen is soft, no hepatosplenomegaly.

Hernial orifices are normal.

No bruits

Bowel sounds are heard

Genitals- Normal.

 

CNS EXAMINATION:

Mental Status:

Patient was conscious, coherent ,cooperative. Well oriented to time, place and person.

 Language: Fluent, able to name relatives, follows commands 

Cranial Nerves- intact

Motor:

Upper Limb:

Pronator drift absent.

Tone:

Increased in both Upper and Lower limbs, asymmetrically.

Power:

Upper Limbs:3/5 in both limbs

Lower limbs: 2/5 in both limbs

Tremors:

Fine tremor present when arms are outstretched.

Posture:

On standing, patient is seen to be stooping.

Patient unable to walk by himself, needs support to stand and walk.

Finger to Nose Testing:

Normal

Rapid alternating Movements : Normal

Romberg: Negative

Proprioception:

Reflexes: Not able to elicit.

Babinski: Flexor response

Sensory Examination

Vibration: Normal

Joint position sense : Normal

Pin prick, temperature sensation: Normal

CVS:

S1, S2 Heard, No murmurs

RS:

Dyspnoea: Present

BAE present, NVBS heard

No adventitious sounds

INVESTIGATION

Hemogram 

1/12/23

2/12/23

Rft

1/12/23

2/12/23

Ecg

Electrolytes 

Treatment given

 INJ. PIPTAZ 2.25 GM IV TID

INJ. LASIX 40 MG IV BD

INJ. NODOSIS 500 MG PO BD

TAB. ECOSPRIN-AV 75/10 O/HS

TAB MET-XL  25 MG PO/OD

TAB NICARDIA 10 MG PO/OD

TAB. DOLO 650 O]PO TID

TAB. SHELCAL CT PO OD

TAB. OROFER XT

INJ EPO 4000 U SC/ ONCE WEEKLY

INJ. IRON SUCROSE 200 MG IN 100 ML NS / WEEKLY ONCE