A 55 year old male with SOB

February 21, 2022

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

A 55 year old male, farmer by occupation and a resident of rajammagudam, came with the chief complaints of

* Shortness of breath since 1 week

* Pedal edema since 3 days

* Decreased urine output since 3 days.

HISTORY OF PRESENTING ILLNESS

* The patient was apparently assymptomatic 3 years back when he was diagnosed with diabetes when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication.

1 year ago patient was having blurring of vision and dizziness for which he went to the doctor and was diagnosed with hypertension and was given amlodipine. He is compliant with the medication.

The patient complains of shortness of breath since 1 year. It was initially of grade 2(MMRC Classification) that is he has to stop to take breath while walking at his own pace. For this he went to a local doctor and was given a tablet (unknown).

- The shortness of breath has aggrevated to grade 4 MMRC classification

- The shortness of breath was associated with PND and orthopnea. It was not associated with chest pain or palpitations.

- The patient also complains of non productive cough since 3 days.

The patient has had decreased urine output for the past three days. In the 24hrs before admission he did not have any urine output.

- He doesn’t have any hesitancy, increased frequency or fullness of bladder.

Pedal edema since 3 days

He had first session of dialysis on the day of admission 19/02/22 ( indication was metabolic acidosis ph 7.19)

Other two sessions on 20/02/22 and 21/02/22

PAST HISTORY

he was diagnosed with diabetes 3 years ago when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication.

diagnosed with hypertension 1 year ago and was given amlodipine. He is compliant with the medication.

He is not a known case of coronary artery diseases, Asthma, TB, epilepsy.

PERSONAL HISTORY

Appetite: decreased

Diet : mixed

Bowel: normal

Bladder : decreased urine output

Sleep: disturbed

Addictions: nil

GENERAL EXAMINATION :

Patient is conscious,coherent,cooperative coherent, cooperative and well oriented to time and place

Moderately built and nourished