60 year old male with B/ L pedal edema and shortness of breath

Name- M. Sri Nithya


Roll. No- 75


 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. 

Following is the view of my case: (history as per date of admission)

 60 year old male patient came to the casuality with the chief complaints of 
B/L pedal edema since 20 days
SOB since 3 days.

History of present illness:
Patient was apparently asymptomatic 20 days back then he developed B/L pedal edema which is of non- pitting type. 
History of SOB since 3 days ( MMRC grading - 1/2)
There is no history of fever, cough, decreased urine output, chest pain, abdominal pain or trauma.

Past History:

 He is known case of hypertension since 3 years and diabetes mellitus since 5 years but patient uses medications intermittently.

There is no history of TB, asthma, , cardiovascular diseases.

No H/O previous surgeries.


Personal history

Appetite- normal

Diet -mixed

 bowel and bladder -regular

Sleep- adequate

Addictions-He is a chronic smoker since 45 years

He is  chronic alcoholic since 45 years

No known allergies.


Family history

No significant family history.


General examination

Patient is examined in a well lit room with informed consent. 

He is conscious, coherent, co-operative,well oriented to time,place and person.

He is moderately built and moderately nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Edema - present B/l pedal edema, non - pitting type


Vitals:

Temperature-afebrile
Heart rate-79 beats/min
Blood pressure-140/100mmHg
Respiratory rate-29cycles/min
SPO2-98% at room air

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard
         No added thrills, murmurs

RESPIRATORY SYSTEM: 

Trachea is central,
B/l Crepitations were heard in the mid axillary line.
There is no wheeze but dyspnea is present.


CENTRAL NERVOUS SYSTEM: 
Level of consciousness : conscious to time, place, person
Speech: normal
Cranial nerves -Normal
Motor and sensory: normal 


INVESTIGATIONS:


Diagnosis: CKD on MHD

Treatment:

Fluid restriction Less than 1.5 litres/ day

Salt restriction Less than 2g/ day

Inj. Lasic 40 mg I.V OD 

Tab. Nodosis 500 mg BD

Inj. Erythropoeitin 4000 IU S/c weakly once

 Inj. HAI S/C 6 U. TID



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