A 58 year old male with shortness of breath 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.

This is a case of a 58 year old male who came with a chief complaint of shortness of breath since 6 days and decreased urine output since 15 days.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 9 years ago and then he came down with a fever associated with chills. He also developed pedal edema and shortness of breath grade 4 not associated with orthopnea or pnd. He lost consciousness and was immediately taken to a local hospital. There he was diagnosed with hypertension, diabetes and chronic kidney disease. He was treated and took medication regularly and his illness subsided.

After that he felt fine and continued with his life until 5 years back, he had another episode of losing consciousness. This time it was associated with loss of vision, loss of sensation and inability to talk.

He also had shortness of breath of grade 4 not associated with orthopnea or pnd. He was taken to the hospital again and went home after being treated. He was bed ridden for 3-4 months and then he was able to pursue his daily activities again.

4 years back he had another episode of shortness of breath and was taken to the hospital again and symptomaticaly managed

1 month back, he developed a swelling in his perianal region associated with excruciating pain and fever with chills. He took painkillers for 15 days continuously, multiple tablets a day until his family found out and forced him to stop. He was then taken to the hospital and they gave him some medication which he used for 10-15 days.

Since 15 days he hasn’t been able to pass urine properly. 6 days back he developed shortness of breath grade 4 and was brought to the hospital again. He seems to be very anxious and has been experiencing sleep disturbances. He also keeps trembling and shivering

The patient also complains of recurring pedal edema. The edema often reaches up to his knees and aggregates with work and decreases with medication. At present he has no pedal edema.

Daily routine:

The patient is a farmer by occupation and works in paddy fields and takes care of livestock.

He wakes up at 4 am everyday and freshens up. Then at 8 am he goes to his fields and works for some time until 10 AM. He comes back, has food takes some rest until 1 PM. He goes and works until 5 PM. After that he chats with his family and neighbours and then has dinner at 8 PM. He sleeps by 9 PM.

PAST HISTORY

Was a chronic alcoholic until 10 years back for 30 years. He drank 90 ml everyday

Was a chronic smoker until 10 years back for 30 years. He smoked a bundle of beedis everyday

PERSONAL HISTORY

Diet: mixed

Appetite: decreased

Sleep: has sleep disturbances since the past few days.

GENERAL EXAMINATION

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

Pallor: present

Icterus: absent

Clubbing: present