A 42 y male with hypertension since 1 year which was incidentally detected during hospital visit due to fever post covid vaccination

- July 02, 2023

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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 42 year male daily wage labourer by occupation came to opd for regular dialysis.

History of presenting illness:

Patient was apparently asymptomatic 1.5yr back

Then after taking covid vaccination he developed fever which was present through out the day

Not associated with vomitings,nausea,burning micturition

Generalised weakness was present which didn't got relived on taking medications

So he visited our hospital.

Then he was diagnosed with hypertension and renal cyst. For which he was given medication.

After 6 months he developed shortness of breath and pedal edema upto ankle for a week. Then they visited Gandhi hospital

Where dialysis was done for him and was admitted in hospital for nearly 20 days

And then medications were given.

2 months back he developed shortness of breath and generalised weakness again

Now he visited our hospital. His hemoglobin levels are low so blood transfusion of 4 units was done .since then he was on regular dialysis which is twice in a week.

15 days back after dialysis was done

He developed watering eye in the right eye,peri orbital swelling was developed,tenderness was present,no eryyhema

And then gradually vision was lost in that eye with in 5 days.

After 7 days he noticed nasal bleeding from right nostril. He also develped an ulcer like wound on his right nadolabial fold of nose.He also developed a swelling on the scalp on right side for which he was treated with fudic ointment.

Past history

Known case of hypertension since 1 year and on medication

Initially 1 year back he used to take 1 tablet /day now he is using 3 tablets / day

Not a known case of diabetes,TB,asthma

Personal history

Mixed diet

Appetite is reduced

Normal bowel and bladder movements

Sleep is adequate

Addictions

Chronic alcoholic

Daily consumption of alcohol around 250 mL for around 20-25 yrs and stopped 1 1/2 yr back

Daily routine

Before 6 months

He used to wake up at 5:00am and does some house hold works and goes to work at 8:00 am after having breakfast and returns home at 3:00 pm for lunch and goes back to work and again returns home back between 8-9pm and will have dinner and sleep

Now

He wakes up around 7:00 am and after taking shower will have breakfast by 8:00 am and then sleeps again and wakes up at 2:00 pm for lunch takes his medications and sleeps again and wakes up again at 8 pm will have dinner and sleeps again.

Family history:

Not significant

General examination

Patient was conscious ,coherent and well oriented to time and place.

Patient was moderately built and nourished

Vitals

Blood pressure : 160/100 mm Hg

Respiratory rate: 17 cycles /min

Pulse: 80 beats/min

Temperature: 99 F

Pallor is present

No icterus,cyanosis,clubbing,lymphadenopathy