57 year old male with sob and decreased urine output

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 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 

CNS no focal neurological deficits 

INVESTIGATIONS






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