57 YEARS OLD MALE PRESENTED WITH C/O PEDAL EDEMA AND SOB

 MEDICAL CASE 

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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 cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

November 29 2021

YOGITA AILANI

Roll no:149

CASE DISCUSSION

57 YEAR MALE PRESENTED WITH C/O PEDAL EDEMA AND SOB

HISTORY OF PRESENTING ILLNESS

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 5 YEARS BACK THEN HE HAD C/O POLYURIA, POLYDIPSIA. ON ROUTINE INVESTIGATIONS HE WAS DIAGNOSED AS DM type 2 AND HTN. FOR WHICH HE WAS ADVISED TO TAKE MEDICATION.

3 YEARS BACK HAD C/O B/LPEDAL EDEMA-VISITED HOSPITAL AFTER INVESTIGATIONS WAS DIAGNOSED AS RENAL FAILURE.PATIENT WAS ON MEDICAL TREATMENT FOR FEW MONTHS.

AFTER FEW MONTHS HE HAD LEFT SIDE MOUTH AND HAND DEVIATION WITH SLURRED SPEECH,

FOR WHICH HE WAS TAKEN TO HOSPITAL AND WAS ALRIGHT AFTER 1 DAY.

2 YEARS BACK HE HAD ALTERED SENSORIUM FOR WHICH HE WAS TAKEN TO HOSPITAL AND WAS DIAGNOSED TO HAVE BRAIN STROKE. DISCHARGED  AFTER 1 WEEK AND WAS ON MEDICAL TREATMENT FOR FEW MONTHS.

1 YEAR BACK HAD AN EPISODE OF HEMIPLEGIA, HE WAS TAKEN TO HOSPITAL. 

PATIENT WAS ON ANTI-PLATELETS AND PHYSIOTHERAPY.

AFTER 6 MONTHS HE DISCONTINUED ALL THE MEDICATIONS.

HE WAS TAKED TO AN AYURVEDIC DOCTOR AND WAS USING THOSE MEDICATIONS FOR FEW MONTHS.

ON 1st Nov 2021- HE DEVELOPED GENERALISED EDEMA, LOSS OF APPETITE, DIARRHOEA.

ON 10th Nov 2021 - HE WAS TAKEN TO A HOSPITAL IN HYDERABAD WITH C/O PEDAL EDEMA, SOB, ABDOMINAL DISTENTION FOR ONE DAY AND WAS INITIATED ON DIALYSIS (2 sessions were done alternately).

On 14th Nov 2021- THEY VISITED OUR HOSPITAL FOR CONTINUATION OF DIALYSIS.

DIALYSIS WAS INITIATED ON 3rd DAY OF ADMISSION  4 SESSIONS WERE DONE ON ALTERNATE DAYS. 

THE PATIENT WAS DISCHARGED ON 23rd Nov 2021 AND WAS ADVISED TO COME AFTER 3 DAYS FOR DIALYSIS. (But they did not come)

THE PATIENT WAS RE-ADMITTED TO OUR HOSPITAL ON 29th Nov 2021 WITH C/O OF HEMATEMESIS.

PAST HISTORY

He was diagnosed with DM TYPE II and HTN since 4 yrs 

FAMILY HISTORY

No similar complaints in the family.

PERSONAL HISTORY

Diet                   - Veg (Stopped Non-Veg 1yr back)

Sleep                - Adequate

Appetite            - Lost from past 20 days

Bowl & Bladder - Irregular

Addictions         - Regular toddy drinker (everyday 1-2 liters) from 10 yrs of age, occasional alcohol drinker from past 20yrs - STOPPED EVERYTHING FROM PAST 1 YEAR.

TREATMENT HISTORY

Patient is on medication for DM and HTN from past 5yrs.

GENERAL EXAMINATON

The patient was drowsy and irritable.

Not oriented to time place and person.

Icterus                    - Absent

Pallor                      - Present 

Clubbing                 - Absent

Cynosis                   - Absent

Lymphadenopathy  - Absent

Edema                    - B/L pitting type of edema upto ankles

VITALS

                     

• temperature : afebrile
• pulse rate : 89bpm
• respiratiory rate : 12cpm
• blood pressure : 140/90mmHg
• spo2 at room air : 100% at RA
• GRBS : 101mg/dl

SYSTEMIC EXAMINATION 

• CVS: S1.S2 HEARD
• RS: BAE+, NVBS +
• P/A: SOFT, NON TENDER 

• CNS Examination - 

HMF - Can’t be elicited

Cranial nerves - Can’t be elicited

Sensory system - 

• Loss of sensation in left side upper and lower limb.                      

               

Motor system -

• Tone - Normal
• Power -                    R               L

              Upper limbs       5 / 5         4- / 5

              Lower limbs       5 / 5          4- / 5

• Reflexes - 

                              B      T      S      K      A     

                Right -  2+    2+       -      -       -     

                  Left -    +      +        -     -        -   

            Plantar Right - flexor                                                                                                                                                    

                           Left - mute

INVESTIGATIONS

DAY WISE PROGRESS OF PATIENT 

Date: 29/11/2021

RBS

RFT

LFT

SERUM IRON

HEMOGRAM

ABG

HBsAg-RAPID

HIV 1/2 RAPID TEST

AntiHCV Antibodies - RAPID

URINE PROTEIN / CRETININE RATIO

Date: 30/11/2021

RFT

ABG

PROVISIONAL DIAGNOSIS

Chronic Kidney Disease with DM type 2 and HTN, 

Left side CVA

TREATMENT

1. FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2.4 GM/DAY

3. INJ. LASIX 40 MG IV/BD (IF SBP >110 MM HG)

4. TAB. CINOD 10 MG PO/BD

5. TAB. NODOSIS 500MG PO/TID

6. TAB. SHELCAL- CT PO/OD

7. TAB. BIO D3 0.25 MG PO/OD

8. TAB. ECOSPIRIN- AV (10/75) PO/HS

9. GRBS 6TH HRLY (PRE MEAL)

10. INJ. HAI S/C ACC TO SLIDING SCALE 8AM - 2PM - 8PM

11. MONITOR VITALS

12. 1/0 CHARTING

I would like to thank Rakesh Biswas Sir for providing us this opportunity.