A 45 year old male with breathlessness since 10 days and decreased urine output since 5 days

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I've 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 a diagnosis and treatment plan.

C/o breathlessness since 10 days

C/o decreased urinary output since 5 days.

A 45 year old male ,farmer by occupation came to casuality with c/o breathlessness since 10 days which was insidious in onset,gradually progressive with ordinary physical activity.h/o diurnal variation(more duringnight than day), h/o orthopnea,no h/o seasonal variation,no h/o pnd,no h/o chest pain ,palpitations,syncope.

H/o cough since 10 days,moderate quantity,non foulsmelling,non blood stained,not associated with chest pain on coughing.

H/o decreased urinary output since 5 days no c/o burning micturation

H/o 1 episode of fever from yesterday night ,not associated with chills and rigors,relieved upon taking on medication.

No h/o cold/headache.

Did not pass facece since 3 days.h/o passage of flatus present.

H/o joint pains since 6 years which started with left knee>right knee>u/l small joints>elbow and ankle with pain, swelling and tenderness and restriction of movements ,with earlymorning stiffness and relieved as the day progress.

H/o nsaid abuse.

PAST HISTORY-

Not a k/c/o HTN,DM,ASTHMA,EPILEPSY,CVA,CAD,CKD,THYROID DISORDER.

PERSONAL HISTORY-

sleep normal, appetite adequate, bladder- movements, bowel -did not pass stools since 3 days,flatus passed(previously regular).

O/E-patient is c/c/c and well oriented to time place and person

No pallor ,cyanosis,icterus,malnutrition, clubbing of fingers

Pitting type of edema present upto knee

Bp-120/80,

Pr-98bpm

Rr-22cpm

Temp-101.8 F

Spo2-98@RA

Grbs-158 mg%

SYSTEMIC EXAMINATION-

CVS-S1 S2 heard, no thrills and no murmurs

RS-bae+,trachea central,nvbs,no adventitious sound

P/A-soft,non tender

CNS-conscious,no focal deficit

PROVISIONAL DIAGNOSIS- HERT FAILURE WITH HYPONATREMIA?RHEUMATOID ARTHRITIS WITH LRTI

TREATMENT-

1.Inj AUGMENTIN 1.2 GM IV/BD

2. TAB AZITHROMYCIN 500 GM PO/BD

3. INJ LASIX 20 MG IV/BD

4. TAB MET XL 1.25 MG PI/OD

5. INJ . NEOMOL 1GM IV/SOS

6.TAB DOLO 750 MG PO/TID

7. TAB MVT PO/OD

8.DUOLIN NEBULISATION 6 HRLY

9. TAB ACEBROPHYLLINE 100 MG PO/BD

10.SYP. GRILLINCTUS 10 ML PO/TID

11.TAB ULTRACET PO/TID

12. TAB PAN 40 MG IV/BD

13. SYP SUCRALFATE 15 ML PO/TID