42 M resident of choutuppal;daily wage worker by occupation

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan 

A 42year old male daily worker by occupation resident of choutuppal came to general medicine department with chief complaints of

Bilateral pedal edema since 1 month

Decreased appetite since 1 month

Shortness of breath since 1 weeek

HISTORY OF PRESENTING ILLNESS:-

1.5 year back:-

Patient was  apparently asymptomatic 18 months back then he developed pedal edema insidious in onset for which he visited to Gandhi hospital and diagnosed as some kidney problem for which he underwent dialysis for 1month and got relieved.

1 month back

He  developed bilateral pedal edema pitting type insidious onset gradually progressive with no aggravating and relieving factors and got relieved after having dialysis{1month} (at present no edema)

History of decreased appetite since 1 month 

History of shortness of breath insidious in onset and gradually progressed from Grade 2 to Grade 3. with no aggravating or relieving factors.

History of watering in right eye  10 days back for which visited local hospital in choutuppal.At present there is complete loss of vision in right eye and also loss of eye movements in right eye.

History of vesicles first seen on upper part of nose then it spread to lower part;associated with itching.

History of bleeding from nose which resolved spontaneously.

No history of chest pain,orthopnea,palpitations.

No history of fever,vomitings.

PAST HISTORY:-

He is known case of hypertension since 1 year and taking medications regularly(medication-unknown)

No history of diabetes mellitus,tuberculosis,asthma,epilepsy.

history of fall from height 6 years ago due to which he suffered lower limb fracture 

PERSONAL HISTORY:-

Diet-mixed

Sleep-adequate

Apetite-Decreased

Bowel and bladder-Regular

Addictions-Alcohol

Stopped 1 year back.He used to take 90ml whiskey everyday since 20 years.

Allergy-No 

DAILY ROUTINE:-

FAMILY HISTORY:-

No significant family history

General examination:-

Patient is conscious,coherent,cooperative well oriented to time,place and person.Patient is moderately built and nourished.

Pallor-present

Icterus-No

Cyanosis-No

Clubbing-No

Lymphadenopathy-No

At present no edema is seen.

VITALS:-

Temperature-Afebrile

RR-16cpm

Blood pressure-140/90mmhg

Pulse rate-100bpm

 

SYSTEMIC EXAMINATION:-

CARDIOVASCULAR SYSTEM:-

Inspection:-

JVP not seen

Shape of chest-normal

apex beat not visible

Palpation:-

no heaves

no thrills

apex beat heard in 6th intercoastal space lateral to mid clavicular line

Ausculatation-

S1 and S2 heard

RESIRATORY SYSTEM:-

Chest is bilaterally symmetrical

Bilateral air entry present

No scars and sinuses

On percussion:-

Resonant in all nine quadrants

On auscultation:-

Normal vesicular breath sounds heard

PER ABDOMEN:-

Ubilicus-Central

No tenderness

No local rise of temperature

No organomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION:-

Higher mental functions:-

Patient is conscious and well oriented to time place and person 

Speech and language are normal

Extra ocular movements-Absent on right side

Direct light reflex-Absent on right side.

Indirect light reflex-Absent on right side.

No signs of meningeal irritation:-

No neck stiffness noted

Negative Kernigs sign and bruzdinki sign 

INVESTIGATIONS:-

HBsAg-RAPD:-NEGATIVE

HIV 1/2 Rapid test:-Non Reactive

Blood grouping and Rh typing:- B +

HEMOGRAM:-

Hb:-8.8gm/dl

RBC count:-2.5millions/cubicmm

Total count:-21,500cells/cubicmm

Neutrophils-82%

Lymphocytes-10%

Platelets:-1.5laks/cubicmm

SMEAR :-Normocytic normochromic

Platelets:-Adequate in number and distribution

No hemoparasites seen

Blood Urea:-139mg/dl

Serum creatinine:-14.1mg/dl

LIVER FUNCTION TEST:-

Total bilirubin:-0.65mg/dl

Direct bilirubin:-0.15mg/dl

SGOT:-11 IU/L

SGPT:-10 IU/L

Alkaline phospatase:-268 IU/L

Albumin:-3.06gm/dl

Total proteins:-6gm/dl

A/G ratio:-1.04

SERUM ELECTROLYTESL:-

Sodium:-138 mEq/L

Potassium:-2.8 mEq/L

Chloride:-103 mEq/L

ECG:-

PROVISIONAL DIAGNOSIS:-

Chronic kidney disease on maintenance hemodialysis and heart failure?

TREATMENT:-

Fluid restriction <2L

Salt restriction <2g

Tab.Nicardia 10mg

Tab.Shelcal 500mg

Tab.Bio-D3

Tropicamide and phenylephrine eye drops