A 70 year old male patient presented to the opd with fever, vomitings and loose stools

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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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Case Scenario

Nephrology Ward

DOA: 14-06-23

 

Chief complaints

A 70 year old man resident of Nagarkal came to the OPD with chief complaints of: 

- vomiting since 15 days associated with nausea

- diarrhoea since 15 days

- bilateral upper limb and lower limb swelling since 15 days

- fever since 15 days 

History of Presenting Illness

- patient was apparently asymptomatic 20 years ago when he developed knee pain and back pain for which he used unspecified analgesics till the symptoms subsided.

- then 5 years ago he fell while working in the farm and had a fracture of right femur for which he took ayurvedic treatment.

- 1 year ago he had a RTA which caused fracture of right femur for which rod was placed surgically. At this time he was also diagnosed with reanl failure for which he is under conservative management.

- 15 days ago he developed nausea and vomiting 3 episodes for 2 days non-projectile and bilious.

- 15 days ago he had loose stools 3 episodes for 2 days which was watery and black colored.

- 15 days ago he developed bilateral upper limb and lower limb edema.

- 15 days ago he developed fever of moderate grade, continuous and relieved on medication.

- no shortness of breath, burning micturition, reduced urine output, headache and blurring of vision.

Past History

- he was diagnosed with tuberculosis 10 years ago after he developed cough with sputum and fatigue for which he underwent ATT for 7 months after which it was resolved.

- n/k/c/o HTN, DM, CAD, epilepsy, asthma, thyroid disorder.

- no h/o of blood transfusions.

Surgical History 

- Right femur fracture surgery 1 year ago

Personal History

- married

- Used to work as a farmer but stopped working since 5 years 

- changed to vegetarian diet since 1 year 

- decreased appetite since 15 days 

- adequate sleep

- regular bowels

- normal micturition

- no known allergies

- no addictions

Family History

- h/o TB (father)

- no HTN

- no DM

- no heart disease

- no stroke

- no cancer

- no asthma

- no other hereditary diseases

General Examination

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time and space

- well built and adequately nourished

- no pallor

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- bilateral upper limb and lower limb edema present

- no malnutrition 

- no dehydration 

Vitals

- Temperature: afebrile 

- Pulse rate: 92 bpm, regular rhythm, normal volume

- Respiratory rate: 16 cpm

- BP: 110/70 mm Hg

- SPO2: 98% at RA

- GRBS: 173 mg/dl

Systemic Examination

CARDIOVASCULAR SYSTEM

Inspection : 

-Shape of chest: elliptical 

-No engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

- no cardiac thrills 

Auscultation : 

- S1,S2 are heard

- no murmurs

RESPIRATORY SYSTEM

Patient examined in sitting position

Inspection:

- Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

-Chest appears Bilaterally symmetrical & elliptical in shape

-Respiratory movements appear equal on both sides and it's abdominothoracic type. 

-Trachea central in position & Nipples are in 5th Intercoastal space

-No dilated veins,sinuses, visible pulsations.

Palpation:

-All inspiratory findings confirmed

-Trachea central in position

Percussion: Resonant 

Auscultation:

-Infraclavicular- (NVBS) (NVBS)

-Mammary- (NVBS) (NVBS)

-Axillary- (NVBS) (NVBS)

-Infra axillary-(NVBS) (NVBS)                 

-Suprascapular- (NVBS) (NVBS)

-Interscapular- (NVBS) (NVBS)

-Infrascapular- (NVBS)(NVBS)

ABDOMEN 

- shape: scaphoid

- no tenderness

- no palpable mass

- no bruits

- no free fluid

- hernias orifices: normal

- liver: not palpable 

- spleen : not palpable

- bowel sounds heard

- genitals:

- speculum examination :

- P/R examination : 

CENTRAL NERVOUS SYSTEM

- conscious 

- normal speech

- no neck stiffness

- no Kerning's sign

- cranial nerves: normal

- sensory : normal

- motor: normal

- reflexes: all present bilaterally

- finger nose in coordination: normal 

- knee heel in coordination: normal 

- gait: normal

Investigations 

ECG