A 38/M WITH SHORTNESS OF BREATH AND PEDAL EDEMA

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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. 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.

NARENDRUNI KARTHEEK

ROLL NO 102

A 38 year old male resident of tummalaguda, laborer by occupation came to OPD with

CHIEF COMPLAINTS :

bilateral pedal edema since 15 days.
shortness of breath since 15 days.

HISTORYOF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 years ago, then he developed generalized weakness for which he went to a hospital and got diagnosed with hypertension. He was normal and doing his routine work for 2 years;An year ago, he developed bilateral pedal edema which is pitting in type initially till the ankles and extending till the knees now;

also he developed shortness of breath which was insidious onset, grade 2 when he noticed at first during his work hour which was aggravated by doing his work and relieved by rest and progressed to grade 4 now persisting even at rest and relieved by medication

PAST HISTORY :

history of similar complaints 9 months ago, went to a local hospital and got diagnosed as CKD.
history of HYPERTENSION since 3 years.
no history of diabetes, epilepsy, TB, asthma, CAD.

PERSONAL HISTORY:

Patient used to wake up at 4-5 AM IN the morning and does his daily morning routine and he used to start by 6 AM at home in order to reach the place of work. He usually don't carry his breakfast as it is early in the morning. He does his breakfast roadside, he goes to work.
he is a heavy worker which includes heavy weight lifting and putting cement on the walls for constructions.
he comes back to home at 7-8PM in the evening
haves dinner at 9 PM, usually sleeps at 10-11 PM.
he takes mixed diet, consumes non vegetarian diet weekly twice
his appetite is decreased from the past 15-20 days, he complains of shortness of breath even after taking food, so for this reason he is avoiding food as it aggravates his condition.
his sleep is disturbed and he cant sleep due to shortness.
bowel movements- regular
bladder movements- urinates twice a day only, reduced urine output.
he used to consume alcohol occasionally (once or twice in an year) as per him and his mother and according to his wife he consumes alcohol daily since their marriage because she used to observe smell daily; smokes cigarettes- history is not reliable.
since 3-4 years work load is increased on him, he felt body pains for which he took some OTC pain killers- used occasionally for last 2-3 years.

TREATMENT HISTORY :