57 year old male with B/L pedal edema
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 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
2D echo:
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
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