Final long case

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 
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 a diagnosis and treatment plan.


A 58 yr old male patient Daily worker by occupation Came to OPD on 11 January 4.57pm

CHEIF COMPLAINT:
Patient came to OPD 7 days ago with chief complaint of 
  Shortness of breath since 7 days SOB grade III relieved on sitting position ,increases while lying 
  Cold & cough since 6 days
pedal edema, decreased urine output  since 6 days
HISTORY OF PRESENT ILLNESS:
 - Patient was apparently asymptomatic 1 yr back, then he developed Shortness of breath, cough, pedal edema, decreased urine output, distended abdomen
- He was taken to hospital and diagnosed to have renal failure and heart failure 
- He was suggested dialysis but refused and was on conservative management
- SOB grade III relieved on sitting position ,increases while lying 
- orthopnea
- cough,cold, fever ( intermittent)
- sputum is mucoid 

HISTORY OF PAST ILLNESS:
 Is a K/C/O HTN since 1 yr (on medication with clonidine)
Not a K/C/O DM, Asthma, CAD, Epilepsy

PERSONAL HISTORY :
Diet : mixed
   Appetite: normal
   Sleep : adequate
   Bowel and bladder movements: regular
   addictions: Alcoholic stopped since 1yr
                            Beedi (1pack per day)
   No allergies

GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative
Well oriented to time and place 
- No pallor
-No icterus
No lymphadenopathy
-No cyanosis
-No clubbing of fingers 
- pedal edema subsided
VITALS:
Temperature - 99F 
Pulse rate -96 bpm
Respiration rate -16cpm
Bp-140/80 mm Hg
Spo -96%
SYSTEMIC EXAMINATION:
🔹RESPIRATORY SYSTEM 
INSPECTION :-
Chest movements: Bilaterally symmetrical
Trachea is central in position 
No scars 
 PALPATION:-
All inspiratory findings are confirmed
Vocal fremitus decreased (left side mammary ,infrascapular)
Trachea is central in position
 PERCUSSION:-
     Stony dull heard in left mammary region
 AUSCULTATION:-
 Breathe sounds : diminished on left side (mammary, infra scapular region)
  Vocal resonance :decreased ( left side mammary ,infrascapular)
   Added sounds : Crepts 
🔹ABDOMEN:
INSPECTION:
 shape of abdomen: distended 
 Free fluid :yes
 Umbilicus :Inverted
 No dilated veins 
 No scars and sinuses 
PALPATION:
Non tender
No Local rise of temperature 
No palpable Mass 
Spleen and liver not palpable 
AUSCULTATION:
Bowel sounds are heard 
🔹CNS :
- Speech is normal 
- cranial nerve: intact 
🔹CVS :
-S1, S2 are heard
- No murmurs

INVESTIGATIONS:
  ECG:








TREATMENT:
T.NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Inj. Erythropoietin 4000 IU S/C weekly once 

DIAGNOSIS:
Chronic kidney disease
Bilateral pleural effusion 
Right heart failure
Anemia 
Hypertension 

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