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 diagnosis with a treatment plan.
This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.
A 68 year old male patient, resident of Nalgonda who was farmer by occupation came to OPD with chief complaints of:
-swelling of legs since 10 days
-shortness of breath since 10 days
-palpitations since 10 days
-loss of appetite since 10 days
History of presenting illness:
Patient was apparently asymptomatic 10 years back then he had a history of fall and fracture of hip on right side then traction was done.
Then pain in the back in loin region started 4 years back in Dec,2019, which was dragging type which temporarily relieved on taking medication. Pedal edema and SOB also started and SOB increased on walking .
Investigations done 4 years back on 2/12/19:
Patient was advised to undergo dialysis and 10 sessions were done in Dec 2019 and Jan 2020. As the status of the patient improved, dialysis sessions were stopped. From Jan 2020 to Feb 2022 patient was alright with no pedal edema or shortness of breath. Then 10 days back he observed pedal edema and also shortness of breath which increased on walking (grade III).
Patient is not complaining of any fever,cough. Urine output is normal. Burning micturition is present since 10 days.
Past history:
Patient is a known case of HYPERTENSION and using medication since 4 years.
No h/o DM,asthma,epilepsy
Personal history:
Diet:mixed
Appetite-decreased
Bowel and bladder movements:regular
Sleep: disturbed
Addictions: occasional toddy and alcohol drinker since 15 yrs old. Heavy beedi smoker( 1 packet in 3 days) since 15 yrs old.
VITALS
