37 year male with SOB, decreased urine output, abdominal distension,facial puffiness and pedal edema

Hi , I am Y. Shasshank, 3rd semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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 elog also reflects my patient centered online learning portfolio

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

Patient came with the c/o

SOB,

decreased passage of urine,

abdominal

distension,pedal edema,facial puffiness since 1 day (yesterday morning)

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 day ago, then he developed -

■ SOB -

Since yesterday morning.

It was sudden in onset(he said that,when it started,he was sitting at time) and aggravates on walking,on supine position and decreases when he sleeps in lateral positionposition(both right and left).

Continuous,non progressive.

It is not associated with chest pain.

No h/o cough,sweating, palpitations.

■ Abdominal distension -

Since yesterday, gradually progressive.

■ Decreased urinary output -

He didn't pass urine from yesterday morning to evening.

Then they called RMP doctor.He gave 1 Injection and 2 tablets(details not available)

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After 1 hour he passed urine.

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After that abdominal distension decreased a bit.

There is no loin pain,urgency, frequency,burning micturition,dysuria.

■ Pedal edema -

Since 1 day

Pitting type.

Yesterday it was till knee length, today it decreased and till ankle length.

■ H/o decreased sensation, numbness and tingling sensation in the left lower limb since 10 years.

On asking, he gave a history of fever and pus discharge 4 days ago ,describing below

Patient had purulent secretions from the area just below the scrotum (? fistula) and fever 4 days ago.

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Then he consulted RMP doctor and took AMOXICILLIN, DOMPERIDONE,PARACETAMOL for 3 days.

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Then his fever and pus secretions was decreased.

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But after 2 days he developed edema in both upper and lower limbs and facial puffiness.

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And SOB,abdominal distension and decreased urine output since yesterday morning.

Patient passed flatus on 28/7/23night.

PAST HISTORY

Patient had a similar history of SOB 6 months ago, grade 4.

For that he went to a hospital in Devarkonda.

There doctor said that there is water accumulation in the chest ( ? Hydrothorax) and that will decrease on taking medication

So, he took medication(detials not available)for 1 month and was cured.

H/o epilepsy 15 years ago and not on regular medication.

N/k/c/o TB,asthma,DM,HTN,CVA,CAD

Past surgical history -

Patient fell from the bridge 10 years ago and got spinal injury and spinal surgery was done.

After 3-4 years, he had a thorn prick in the right feet, the infection spreaded(according to patient and the attender)in the leg and amputation was done.

FAMILY HISTORY

Not significant

PERSONAL HISTORY

Patient lives with his wife and 2 daughters.

He stays at home and walks around the home and nearby with the help of Walker after his amputation was done7-8 years ago).

Coming to his life history in short,

10 years ago,

He was auto driver and was living a happy family life with his wife and daughter.

Then he had an accident (he fell from the bridge) and got spinal injury and spinal surgery was done in our hospital.

Then,

7-8 years ago,

He had a thorn prick in the right foot and the infection got spreaded in the right leg.So,Amputation was done.

Since then he has been staying at home.

His wife is daily wage worker, she goes to work and his both the daughters go to school (elder one studies in 12th standard and younger one just started her schooling)and patient lives a daily routine bound life at home.

He was completely fine all these years(didn't visit hospital)

But 6 months ago,

He developed SOB,and for that he visited hospital in Devarkonda.

He wakes up around 6 am, after freshing up, takes a cup of tea, spends time at home(eaither sitting,lying on bed or walking around with the help of Walker)

Then he takes his breakfast around 9 am (rice mainly),lunch around 1 pm(rice) and dinner around 8 pm(rice).

He takes mixed diet, appetite is decreased since 4 days.

He was a regular alcoholic but stopped 1 year ago.No other addictions.

No known allergies

GENERAL EXAMINATION

Well informed consent is taken. Examined in a well lit room.

Patient is conscious coherent and coperative well oriented to time place and person.

Moderately built and moderately Nourished.

Vitals

Afebrile

BP 140/80mmhg

PR 60bpm