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 diagnosis with a treatment plan.

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

        A 68 year old male patient who was a farmer came to casualty with cheif complaints of Swelling of both legs, SOB and palpitations since 10 days and loss of appetite since 12 days.

HOPI: 

Patient was apparently asymptomatic 10 years back, then he fell from a tractor.

H/o injury to right hip from this fall and then traction was done. ( So he used NSAIDs) .

4 years back patient had similar complaints of pedal edema and SOB and pain in the back which was dragging type of pain that relieved on medication.

He was on Dialysis. Patient underwent 10 sessions of dialysis as of now.

Later patient was advised to stop his dialysis.

Past History:

No h/o DM, asthma, epilepsy, CAD

HTN + 

Personal History-

Appetite- Normal

Sleep- Adequate

B&B - Regular

Addictions-  BD (6 per day), occasionally alcoholic and Toddy ( once in Every 3days) since 30 years.

Vitals-

Temp- 98.8 F

PR- 94 bpm

BP- 140/80 mmHg 

RR- 18 cpm

General Examination-

Patient is conscious, coherent and cooperative

No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy.

Edema +



Right leg is short compared to the other






Systemic Examination-

CVS: S1 S2 heard

RS: NVBS heard

PA: Soft, non tender.

CNS: NFN

Investigations-

Hb: 8.3 mg/d

Blood Urea: 113 mg/d

Serum Creatinine: 7.1 mg/d

USG Abdomen

- b/l grade 3 RPD with simple renal cortical cyst

- Urinary bladder wall thickened with diverticulae suggestive of chronic cystitis

- evidence of hyperechoic foci in urinary bladder wall likely emphysematous cystitis

Provisional Diagnosis-

Renal failure

Treatment-

1. Fluid and Salt restriction

2. Tab Lasix 40 mg

3. Tab Nicardia 20 mg 

4. Inj. ERYTHROPOIETIN 4000IU SC .








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