A case of a 63 yr old male with decreased urine output and sob

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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.

A 63 yr old male resident of Ramanpeta a retired accountant came to the OPD with

CHIEF COMPLAINTS:

decreased urine output since 1 day

Shortness of breath since 1 day

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1day ago when he developed decreased urine output which was sudden in onset, associated with urgency and pain.

He has shortness of breath since 1 day which is sudden in onset gradually progressive aggravated on walking and relieved by taking rest.

History of abdominal distention and facial puffiness on and off since 3 months.

No history of fever, chest pain, palpitations, cough and cold.

PAST HISTORY:

Known case of hypertension since 2 years

Known case of CAD 2 years back

Known case of hypothyroidism since 1 yr

Not a known case of diabetes mellitus, epilepsy, asthma .

TREATMENT HISTORY:

T.Ramipril and metoprolol for hypertension

T. Thyronorm for hypothyroidism

Percutaneous Coronary Intervention stenting was done for CAD.

History of haemorrhoidectomy 8 years back.

PERSONAL HISTORY:

Before illness : mixed diet, normal appetite, adequate sleep, regular bowel and bladder movements and no allergies

After illness : Diet : consuming foods like idly milk, reduced bladder movements, regular bowel movements, no allergies

He consumed alcohol regularly since 30 years and smoked about 2-3 packs per day before PCI stent placement and stopped afterwards.

FAMILY HISTORY : not significant

GENERAL EXAMINATION : 

patient was conscious coherent cooperative moderately built moderately nourished.

No pallor, icterus, cyanosis, clubbing and lymphadenopathy.

Vitals : pulse rate : 74 bpm

Respiratory rate : 32 cpm

Temperature : a febrile

 Spo2 : 94%

Blood pressure : 90/60 mm hg

SYSTEMIC EXAMINATION:

Cardiovascular system: 

-S1,S2 heard .no mumurs.

Respiratory system:

-Position of trachea central.

- Bilateral airway entry present.

-Dyspnea present 

- no wheeze.

Abdomen:

-Distended

-No tenderness

-No palpable mass

-Spleen : not palpable

-liver : not palpable.

CNS examination:

Conscious .

no signs of meningeal irritation.

INVESTIGATIONS:

TREATMENT:

Inj. LASIX 

Inj. CEFTRIAXONE

Tab. RAMIPRIL 2.5 mg and METOPROLOL 25mg

Tab. ECOSPORIN

Tab.AZITHROMYCIN

Tab. THYRONORM

Nebulization duoline and budecort