A 70year 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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.This is an a 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.

P.Manogna, Roll no.120

CASE REPORT

A 70year old came to the OPD with

Chief complaints of:

Bilateral pedal edema since 12days

Shortness of breath since 5days 

Decreased urinary output since 5days 

HOPI:

Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and it is of pitting type.

Pigmentation over foot and ankle is seen.

He also developed Shortness of breath which was initially grade 1 and progressed to grade 2

Associated with decrease urinary output since 5days 

8sittings of dialysis were done.

H/o loss of appetite and nausea

No H/o- fever,burning micturation, diarrhoea 

Past history:

Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD

Treatment history: 

NSAID abuse

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- decreased urinary output

Addictions-chronic alcoholic since 30years and Tobacco smoking since 40years.

Family history: Not significant 

General examination:

Patient is conscious,coherent,cooperative and well oriented with time,place,person

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Bilateral pedal edema is present,Upper limb edema

Vitals:

Temperature: 98.4 degree Fahrenheit

BP-100/80mmHg

PR-104bpm

RR-21cpm

Grbs- 147mg/dl

Systemic examination:

Respiratory system:

Inspection-

Trachea-central

Chest appears b/L symmetrical and elliptical in shape 

Palpation-Trachea central in position 

Measurements- 

AP diameter-16cms 

Transverse diameter-26cms 

Percussion               Right              Left

Supraclavicular          R                    R

Infraclavicular            R                    R

Mammary                   R                    R

Axillary                      D                    D

Suprascapular             R                     R

Infrascapular               D                    D

Auscultation:

Decreased breath sounds at axillary and infrascapular region

CVS:

S1,S2 heard

JVP raised, no added murmurs

Per abdomen: Soft, non-tender,

CNS: No focal neurological deficits 

Provisional diagnosis: 

Chronic renal failure with bilateral pleural effusion 

Investigation:

Chest X-Ray:

USG:

Bilateral moderate pleural effusion with collapse of underlying lobes.

Investigations:

23/12/22

Blood sugar-80mg/dl

24/12/22

Blood urea:96mgldl

Serum creatinine:6.4gm/dl

25/12/22

Blood urea-109mg/dl

Serum creatinine-6.6mg/dl

Treatment

*Injection lasix 40 mg iv BD
*TAB nodosis 50 mg po BD
*TAB shelcal 50 mg po BD
* TAB Nicardia 10 mg po BD
* Cap biod3 weekly once
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.