45 YEAR OLD WITH PEDAL EDEMA

SHIVANI THOTA 

MBBS 9th semister ,Roll number: 134

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. 

 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 a  diagnosis and treatment plan.

CASE DISCUSSION:

A 45 year old gentleman resident of suryapet  gas welder and tractor driver by occupation presented with chief complaints of :

• Swelling of both lower limbs since 4 days 

History of presenting illness:

Patient was apparently asymptotic 5 years ago then he developed grade-I shortness of breath which was insidious in onset gradually progressed to grade IV  6 months ago

         Bilateral  pedal edema since 4 days which is pitting type insidious in onset which is aggravated on standing for long hours, relieved on taking rest.it was associated with severe knee pains since 6 months

       He has been experiencing pedal edema on and off since 1 and 1/2 years. 

    Earlier

PAST HISTORY:

 He is a known case of   Diabetes mellitus since 6 yrs 

                                                    Hypertension since 6 months

                      Epilepsy since 1and 1/2 years

Not a known case of tuberculosis,asthma

Treatment history : 

Surgical history  : insignificant

Family history : insignificant 

Personal history:

          Appetite:normal

          Diet:mixed

          Bowel and bladder: regular

          Addictions:

                 consumes alcohol since 20 years(1whisky  bottle per day for 4 days in a week)

             Occasional toddy consumption 

                       Zarda pan  chewing since 6 months

Physical examination 

   

Patient was examined in a well lit room, after taking informed consent. 

 

He was conscious,coherent and cooperative and well oriented to time place and person

 

 Pallor: present

 No Icterus 

 No Cyanosis:

 No Clubbing of fingers

 No koilonychia 

 No Lymphadenopathy

 Pedal edema present 

 

VITALS: Temperature -a febrile

                      Pulse -75bpm

                      BP-

                      RR-18 per minute

Systemic examination 

CVS: S1 and S2 heart sounds heard.No murmurs 

Respiratory system:   Bilateral air enters is present,  normal vesicular breath sounds

Per abdomen:soft non tender,no hepatomegaly,no spleenomegaly 

CNS:intact

Investigation:

On 18/10/2021

CUE: albumin:+ 4

               Sugar: +

               Pus cells:5-6

               Epithelial cells:3-4

               Red blood cells:nil

               Crystals and casts:nil

On 30/10/2021

• Serum creatinine:2.6mg/dl 
• Potassium-4.6 mmol/L
• Reticulocyte count:0.6

      Hemogram:

                         hb-8.7                

                            Tc:9600

                     Neutrophils:53

                    Lymphocytes:38

                    PCV:24.3

                    Platelets 3.15

    LFT: total bilirubin:0.32

           Direct bilirubin:0.13

           ALT:12

           AST:15

           AKP:336

           Total protein:4.5

           A/G:0.97

   Serology negative 

             

                               ECG 

  

On 31/10/2021 

                       USG ABDOMEN

                       

Treatment:

1. Tab. Ecosprin-AV/od/he
2. Tab. Livogen/po/od 
3. Tab NODOSIS 500mg/po/Bp
4. Tab PAN 40 mg po/od
5. Fluid restriction <2liters/day
6. Tab. CEGLIM -1 po