A 54 year old male with bilateral pedal edema
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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Nv Prathyusha
Rollno 100
CASE DISCUSSION
A 54 year old male came with chief complaints of
-bilateral pedal edema since 1 week
-decreased urine output since 1 week.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 5 years back then he developed symptoms like fever which was sudden in onset , vomitings , generalized edema involving legs , hands and face, sweating for which he went to a local hospital in his area where investigations were done and he was diagnosed to have hypertension and was prescribed antihypertensives and was advised to visit our hospital for dialysis as he had kidney damage.
He visited our hospital and was advised for 4 sessions of dialysis despite which his condition didn't improve.
Then he started regular dialysis sessions 10 sessions per month for past 5 years.
He developed bilateral pedal edema since 7 days and decreased urine output since 1 week. The patient complaints of pain in left leg at hip region which was sudden in onset and is unable to walk since 5 days.
PAST HISTORY
10 years back he was diagnosed to have hypothyroidism and started his medications after 1 year.
He is a known case of hypertension since 5 years .
Not a known case of diabetes, asthma , epilepsy, TB, CVA, CAD.
No history of any previous surgeries.
PERSONAL HISTORY
Daily routine before 5 years-
Patient was a supervisor at a paint shop. He used to wake up early in the morning at 6am and used to have 3 meals per day and leave for work and used to come home by 7 pm to spend time with his family. He used to smoke 1-2 beedi per day and used to consume 100ml alcohol per day since past 20 years.
Daily routine from past 5 years-
He stopped working at the shop and stays at home and goes for his weekly dialysis sessions. He takes only 1-2 meals per day and he has given up on his addiction due to his condition. there is weight loss from 80kg to 45 kg from past 5 years.
Appetite is decreased
Diet - vegetarian
Bowel and bladder habits - reduced
Sleep- inadequate.
TREATMENT HISTORY
Since last 5 yrs on -
Tab Nicardia Retard 20mg
Tab Arkamin 100micrograms
Tab Lasix 40 mg
Tab Sobinid 500mg
Tab Calvic-D
Tab Calci
Since last 9 yrs on -
Tab Thyronorm 250 micrograms
FAMILY HISTORY
no significant family history.
GENERAL PHYSICAL EXAMINATION
Patient is conscious, coherent, coperative and we'll oriented to Time place and person.
He is poorly built and nourished.
Pallor is present
Cyanosis, clubbing, generalized lymphadenopathy - absent.
Bilateral pitting type of pedal edema and edema of upper limb.
Vitals on admission -
Temperature - 98F
Pulse rate - 88bpm
Respiratory rate - 16cpm
Blood pressure - 140/90mm hg
SYSTEMIC EXAMINATION
•Cardiovascular system-
S1 and S2 are heard ,no murmurs are heard.
•Respiratory system:
Trachea central, all quadrants of chest moves equally with respiration. No adventitious sounds.
Breath sounds- bilateral normal
Vesicular breath sounds are heard.
•Central nervous system-
No focal neurological deficits
•Abdominal system:
Inspection:
On inspection abdomen is flat, symetrical.
Umbilicus is centre and inverted.
No scars,engorged veins are seen.
All 9 regions of abdomen are equally moving with respiration.
Palpation:
On palpation abdomen is soft and non tender.
All inspectory findings are confirmed.
Percussion:no shifting dullness, no fluid thrills.
Auscultation:normal bowel sounds are heard.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
CKD on MHD.
TREATMENT
Salt restriction less than 2.4 gm /day
Fluid restriction less than 1 litre/day
Tab Nodosis po/Bd
Tab shelcal po/Bd
Orofer XT po/bd
Tab Lasix po/Bd
Tab biod3 weekly once.
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