A 55 year male with Pedal Edema and SOB since 1 month

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

 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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

I have been given this case 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.


CASE SCENARIO : 

A 55 year male came with complaints of pedal Edema since one month
SOB Grade 2 since month

HISTORY OF PRESENTING ILLNESS :

He was apparently asymptomatic since 1 month back then he had a trauma to left LL for which he went to local hospital and used some antibiotics. Then he started developing bilateral pitting type of pedal edema which was below the knees but now progressed to above knees. She then developed SOB Grade 2 since 1 month for which she went to NIMS and undergone 6 sessions and at the same time diagnosed with HTN and she is on Arkamin 0.1 mg PO/BD

HISTORY OF PAST ILLNESS :

He is K/C/O  HTN since 1 month
Not a known case of DM, TB, Epilepsy and Asthma

PERSONAL HISTORY :
Normal appetite
Mixes diet
Normal bowel and bladder movements
No addictions

FAMILY HISTORY :  Not significant



O/E : 

pt is c/c/c,

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - b/l present

Vitals:

Temperature : 99 ° F

Bp: 160/100 mm hg

PR: 80 bpm

RR: 20 cpm

SpO2: 98% @RA litres of oxygen

GRBS : 120 mg %

Systemic examination : 

— CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath sounds : Vescicular

— ABDOMEN 

- Shape of abdomen : obese

- No tenderness , palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are not palpable

- Bowel sounds : Yes 

CNS 

Speech : Normal
Level of conscious : Conscious
No neck stiffness
No kerning's sign
Cranial system : NAD
Motor system : NAD
Sensory system : NAD
Glassgow scale : 15/15

Reflexes-
                    Biceps Triceps Supinator Knees A
RL:.                 +          +           +                +         +
LL:.                  +         +           +                +         +

  Tone: Rt .UL :Normal
             Lf. UL: Normal
             Rt. LL : Normal
             Lf. LL: Normal

Power: Rt .UL: Normal
             Lf. UL: Normal
             Rt. LL: Normal
             Lf. LL: Normal

Cerebral signs :
Finger nose in-coordination : no
Knee heal in-coordination : no

Gait : NAD

INVESTIGATIONS











17-08-2022 :

PROVISIONAL DIAGNOSIS :   CRF , HTN ,CAD 

TREATMENT :

1. Fluid and salt restrictions
2. Tab. Nodosis 500mg PO/BD
3. Tab. Shelcal 500mg PO/OD
4. Tab. Orofer XT PO / OD 
5. Tab. Bio D3 PO (weekly once) 
6. Inj. Erythropoietin 4000 IU / Weekly thrice 
7. Inj. Lasix 40mg IV/BD (if SBP > 110 mm Hg)
8. Tab. Arkami 0.1mg PO/BD
 
18-08-2022 :

PROVISIONAL DIAGNOSIS :   CRF , HTN ,CAD
 
On examination : 

Patient is C/C/C

BP : 140/90 mm of Hg

PR : 66/min

CVS : S1, S2 present

RS : BAE +

P/A soft 

CNS : NAD

TREATMENT :

1. Fluid and salt restrictions
2. Tab. Nodosis 500mg PO/BD
3. Tab. Shelcal 500mg PO/OD
4. Tab. Orofer XT PO / OD 
5. Tab. Bio D3 PO (weekly once) 
6. Inj. Erythropoietin 4000 IU / Weekly thrice 
7. Inj. Lasix 40mg IV/BD (if SBP > 110 mm Hg)
8. Tab. Nicardia 10mg PO/TID 
9. Tab. Ecosprin - IV PO/OD
 



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