57 year old male with B/L pedal edema

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Vignatha 

roll no: 55

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:

Chief complaints

B/L knee pains since 30 days

B/L lower limb swelling since 15 days

Fever since 4 days

Difficulty to walk since 3 days 

Right upper limb swelling since 3 days

HOPI:

Patient was apparently asymptomatic 30 days back then he fell down in field and developed sprain of lower limbs for which he  consulted orthopaedics doctor and was advised rest. 

He continued to walk despite sprain which resulted in pain of bilateral lower limbs 

He also consulted rmp for conservative management (he was given inj diclofenac ).

Patient also came to our hospital where he was prescribed hifenac p for pain relief.

Then after few days patient developed bilateral pedal oedema which extended from thighs to ankles which was of pitting type. Then the patient was unable to walk.

He also developed fever 10 days back and 4 days back which was of low grade and intermittent in night time. Fever was associated with body aches.

It was not associated with chills,rigors, vomitings, loose stools, cough, burning micturition ,chest pain, palpitations.

Not a known case of DM, HTN, ASTHMA, EPILEPSY,CAD





FAMILY HISTORY:

No significant family history 


Personal history: 

Diet: mixed 

Appetite: decreased 

Sleep: adequate 

Bowel and bladder movements : regular 

Addictions: alcoholic since 30 years and drinks thrice in a week 

Smoking since 30 years and smokes 3 to 4 cigarettes per week


General examination:

Patient is conscious, coherent, cooperative 

Well oriented to time, place and person 

No pallor

No icterus 

No cyanosis

No clubbing 

No lymphadenopathy 

Oedema of both foot and right hand present 




Vitals:

Temperature: afebrile

BP:130/80mmHg

PR:100bpm

RR:18cpm

SpO2:97% on RA


Systemic examination 

Cvs:

S1 S2 present 

No thrills 

No murmurs 

Respiratory system:

Vesicular breath sounds 

Position of trachea is central 

No dyspnoea 

No wheeze 


Abdomen:

Is scaphoid

No tenderness 

No palpable masses

No free fluids 

No bruits 

Liver and spleen are not plapable 

Bowel sounds present 


CNS:

Patient is conscious 

Normal speech 

No neck stiffness 

Glasgow scale 15/15

Reflexes normal 


Provisional diagnosis: Acute on chronic hyponatremia

Polyarthralgia under evaluation 



Investigations:

12/12/2022


Hemogram 

Hb: 11.7 mg/dl

Total count:21,700

Neutrophils: 88%

Lymphocytes:04%

Eosinophils:00%

Pcv: 36.1%

Mcv:62.2%

Mch:20.2

Rbc count:5.80

Platelet counts:3.34

Blood group: B POSITIVE 

ESR:25mm/1st hour 


Serum electrolytes:       Repeat samples 

Sodium:115                            110

Potassium:4.3                        4.4

Chloride:93                            90

Calcium ionized:0.88            0.90


Urinary chloride: 147

Spot urine sodium:128

Urine protein/ creatinine ratio:0.19

Phosphorus:2.5

Blood urea :30

Serum creatinine:0.7

Serum osmolality:227.7


Complete urine examination:

Colour : pale yellow

Appearance: clear 

Reaction: acidic 

Sp gravity:1.010

Albumin: nil

Sugar : nil

Bile salts: nil

Bile pigments: nil

Pus cells:2-3

Red blood cells: nil

Crystals: nil

Casts: nil


LFT

Total bilirubin: 1.89

Direct bilirubin:0.96

SGOT:44

SGPT:37

ALP: 298

Total proteins:5.5

Albumin:2.87

A/G ratio: 1.09


C reactive protein: negative 

Rheumatoid factor: negative

Abg on 12/12/22

X ray 




Ecg





2D echo:
Aortic valve: sclerotic
Left atrium:3.5 cms
Left ventricle: no RWMA, concentric LVH present 
ESD: 3.50cms
EDD:5.08cms 
DPW:1.41 cms 
EF:56%
FS:28%
IVS:1.41 
AORTA:3.4
IVC size:1.35 cms , non collapsing 
Impression:
Trivial TR+, AR+, MR+
No RWMA, no AS/MS , sclerotic AV
Good LV systolic function , concentric IVH positive 
Diastolic dysfunction present 
No PAH or PE 

USG ABDOMEN:
Liver size: 15 cms 
Normal echotexture 
No evidence of surface irregularity

Treatment:

INJ MONOCEF 1 GM IV BD

TAB ALDACTONE 50 MG PO OD 

INJ THIAMINE 200MG IN 100ML NS IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

INJ VITCOFOL IM OD 


14/12/22
Hemogram
Hb:10.4
Total count:9,100
Lymphocytes:15
Rbc count:5.50
Platelet count:2.94

Serum electrolytes 
Sodium: 130 
Potassium: 4.2 
Chloride:130 
Calcium ionized : 0.96

Bacterial culture and sensitivity:
No pus cells seen
No growth

Urine chloride : 106 
Urinary potassium: 5.4
Urine sodium: 62
 
X ray

















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