57 year old male with sob and decreased urine output

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

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.


CHIEF COMPLAINTS


decreased urine output since 5 days


Pedal edema since 5 days


Episode of fainting 3 days back


HOPI:


patient was apparently asymptotic 5 days back then he developed decreased urine output and pedal edema then went to a local doctor but the symptoms did not subside. Then he went to hyderabad and received treatment, and felt better. 3 days ago patient had an episode of hypoglycemia and was brought to our hospitalPAST HISTORY: 

K/c/o diabetes since 15 years

K/c/o hypertension since 5 years

History of hypoglycemia 4 years back

History of blebs on toes when he missed the oral hypoglycemics for 2 to 3 days

He had an episode of paralysis of left side 

5 years back which resolved within one hour on treatment 



PERSONAL HISTORY 

Diet:mixed


Appetite:normal


Bowel movements are regular, bladder : decreased urine output 


Addictions: alcohol consumption from past 30years (375ml alcohol 3 to 4 times a week)


No know allergies 


FAMILY HISTORY 


father was a known case of diabetes


Mother was known case of hypertension


GENERAL EXAMINATION


Patient is conscious coherent and cooperative


built: well built and well nourished


Pallor: absent


Icterus: absent


Clubbing: absent


Cyanosis: absent


Lymphadenopathy: absent


Edema: bilateral pitting edema is seenVitals: 


7/10/22


temp: 94.6°f


PR:100 bpm


BP:190/100 mm Hg


RR:16 cpm






RBS: 55 mg/dl


Spo2: 98%


8/10/22


temp: 98.0°f


PR:103 bpm


BP:140/80 mm Hg


RR:18 cpm


RBS: 137 mg/dl


Spo2: 99%


SYSTEMIC EXAMINATION 


CVS: S1 S2 heard, no murmurs heard


RESPIRATORY: BAE +, NVBS heard


P/A: abdomen distended, there are multiple hyperpigmented spots on the right side of the abdomen. Abdomen is soft and nontender on palpation 


CNS no focal neurological deficits 








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