57 year old male with sob 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.
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 hospital
PAST 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 seen
Vitals:
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
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