Medicine case

 

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 72 year old male with bilateral pedal edema,facial puffiness,abdominal distention and decreased urine output.

Name: P.Sai Krupa Sri 

Rollno: 175 

A CASE DISCUSSION ON BILATERAL PEDAL EDEMA,FACIAL PUFFINESS,ABDOMINAL DISTENTION,DECREASED URINE OUTPUT

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.

CASE PRESENTATION:

A 72yr old male, farmer by occupation presented to our opd on 24th november 2021 with

CHEIF COMPLAINTS of

• Bilateral pedal edema since 8months
• Decreased urine output since 8months
• Abdominal distention since 1month
• Shortness of breath since 4days

  HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 8months back later on he developed-

• Bilateral pedal edema since 8months which was gradually progressive pitting type associated with decreased urine output and pain in lower limbs

Patient went to nearby  hospital and their doctor advised to go to nephrologist.

 later he went to another hospital in hyderabad there he was given medications

•  later on 1month ago he developed abdominal distension  and
• Shortness of breath from past 4days and also he is unable to walk since 4days

Patient was on medication in these 8months  and on november 9th he went to hospital in hyderabad there doctor advised to go for dialysis and so patient came for undergoing dialysis in our hospital.

PAST HISTORY:

• Known diabetic and hypertension since 20 years  

• Not a known case of Asthma , Epilepsy ,CAD.

PERSONAL HISTORY:

Appetite: Normal

Diet: Mixed 

Bowel and bladder movements: Regular 

Urine output : Decreased

Addictions: Drinks alcohol

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative.

He is well oriented to time, place and person. 

He is  moderately nourished.

 Pallor- Present

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

Edema - present

VITALS: 

Temperature:98F

Pulse rate:82/min

Respiration rate:16 cycles /min

Bp:160/90mmhg 

SpO2 at room air:98%

SYSTEMIC EXAMINATION:

Respiratory System- BAE+ clear

Normal vesicular breath sounds heard.

CVS- S1 and S2 heard 

CNS- 

Higher mental functions intact 

Cranial nerves intact 

ABDOMEN-

On Inspection:

• Shape-Distended
• No visible scars,orifices

On Palpation:

• Soft and non tender
• No palpable mass
• Liver and spleen not palpable

On auscultation:

• Bowel sounds heard

On percussion:

 Dullness is noted 

REFLEXES-

Present 

Clinical pictures:

INVESTIGATIONS:

Complete Blood Picture:

Complete Urine Examination:

Serum electrolytes:

Random Blood Sugar:

RBS-384mg/dl

Erythrocyte sedimentation rate :- 90mm/1 hour

Serum creatinine - 10.8mg/dl

Blood urea:-240mg/dl

Ultra sound report:

Provisional diagnosis - 

Chronic renal failure secondary to diabetic nephropathy associated with hypertension and diabetes mellitus type2.

TREATMENT:

1. Tab.lasix 40mg po/BD
2. Tab.nodosis 500mg po/BD
3. Tab.orofer xt po/BD
4. Tab.shelcal ct po/OD
5. Inj.erythropoietin 4000IU SC weekly once
6. Inj.HAI s/c
7. Fluid restriction (<1L /day)
8. Salt restriction(<2gm/day).

I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this opportunity