44 Y/O MALE WITH SHORTNESS OF BREATH

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

A 44 year old male, farmer by occupation cane with the chief complaints of

1. Shortness of breath since 10 days

Patient was apparently asymptomatic 10 years back when he was diagnosed with CKD and has been on regular medication ever since.

Additionally, he was diagnosed with DM 5 years back when he went to the doctor with C/O stabbing-type chest pain, for which he has been taking glimepiride.

He was also diagnosed with HTN 1 year back after he had an episode of dizziness with blurring of vision and tachycardia. On visiting the local doctor, he was told that his BP was 160/90mmHg and he was prescribed telmesartan.

He also complained of leg pain since 1month, which was intermittent in nature, throbbing type pain, non radiating, decreased on rest and increased on exercise.

2 weeks ago, he developed fever which was high grade, associated with chills and rigors, and 2 episodes of vomitting (non bilious, non projectile). On visiting the hospital, he was diagnosed with typhoid and treated accordingly with antibiotics. Typhoid was not associated with jaundice, constipation.

10 days back, he developed SOB (grade 2 NYHA) which has no noted aggravating or relieving factors. Not ass with orthopnoea, PND, or cough. No chest pain was noted.

There was also bilateral pedal edema (pitting) since 1 week

Facial puffiness since 1 week

Decreased urine output since 1 week

Epigastric pain since 1 week, with c/o abdominal distention

DAILY ROUTINE

He is a farmer (cotton), and also owns a Kirana shop on the side. Additionally, he works as a watchman between the months of October and March.

Since the pandemic, however, he stopped his duties as a watchman owing to lack of time management, and his hypertension diagnosis.

He usually wakes up at 6am, tends to his farm, had lunch and then goes to his shop for the rest of the evening. Since 2 weeks, however, he has not been going to his shop.

PAST HISTORY

CKD- 10yrs

DM- 5yrs

HTN- 1yr

PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Disturbed

B&B: Regular

Used to smoke (15-20 per day) and drink (quarter per day) but he stopped 10 years ago.

FAMILY HISTORY

Insignificant