A 45 year old male with bilateral pedal oedma, shortness of breath and decreased urinary output.
roll no: 45
I've 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 a diagnosis and treatment plan.
Following is the view of my case:
A 45 year old male came to the hospital with the chief complaints of bilateral pedal oedema, shortness of breath and decresed urinary output.
History of present illness:
Patient was apparently asymptomatic 3 months back then he developed bilateral pedal edema which was painles and it is of pitting type. He also complained of shortness of breath, lower back pain and decreased urinary output. There is no history of fever, nausea and vomitings.
Past illness: He was diagnosed with hypertension 3 months back. There is no history of diabetes, TB, asthma.
Personal history:
Appetite: normal
Diet: mixed
Bowels: normal
Micturition: abmormal
No addictions
Family history: not significant
General examination
Built: moderate
No pallor, icterus, cyanosis, clubbing and lymphadenopathy .
Vitals:
Pulse: 89/min
Respiratory rate:26/min
Temperature: afebrile
Systemic examination
Cvs: s1 and s2 heard
Respiratory system: no dyspnoea and no wheeze.
Abdomen: distended
CNS: Conscious, and speech is normal
Hemogram:
Renal function test
Ascitic fluid amylase
Hemoglobin in ascitic fluid
PCV - Ascitic fluid
SAAG
Ascitic fluid protein sugar
Ultrasound report
Provisional diagnosis
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