A 60 year old male resident with pedal edema
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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 prognosis
A 60 year old male resident of marepally farmer by occupation came to the OPD with the chief complaints of
CHIEF COMPLAINTS:
Burning mituration on and off since 2-3months
Burning sensation near heart since 5 days.
Bilateral pedal edema since 5 days.
Shortness of breath since 5 days.
History of present illness :
patient was apparently asymptomatic 4 years back then he developed lower back pain which was sudden in onset gradually progressive no aggregating and reliving factors and no associated symptoms.
Then he went to hospital where they diagnosed it as kidney failure and on medication since then.
Then 5 days back, he complained of pedal edema which was insidious in onset gradually progressive grade 1 pitting type no aggregating and reliving factors.
Associated with pain in the legs while walking.
Shortness of breath since 5 days grade 3 which is sudden in onset gradually progressive aggravated on walking relieved on taking rest not associated with fever.
Burning sensation in the chest near the heart since 5 days sudden in onset.
History of burning mituration on and off since 2-3 months not associated with fever no frequency, urgency and hesitency.
No history of PND,orthopnea, nausea, vomiting, giddiness,generalised weakness.
History of past illness :
No similar compliants in the past
Known case of diabetes since 8 years.
Known case of hypertension since 6 months.
No history TB,asthma,CHD,CVD,eplipsy.
No drug allergies.
Family history : not significant.
Personal history :
Sleep : adequate
Diet : mixed
Appetite : normal
Bowel and bladder movements : regular
Smoking and alcohol stopped 2 months back.
General examination :
Patient is conscious, coherent , cooperative well oriented to time, place and person.
Moderately built and nourished.
Pallor : mild
Icterus : absent
Cyanosis : absent
Bilateral Pedal edema : present grade 1
Lymphadenopathy : absent
Vitals :
BP : 130/80mm of Hg
Pulse : 86/min
RR : 8/min
Temperature : 98.8F
Spo2 : 97%
GRBS :108 mg%
System examination :
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Treatment :
IV insulin
IV calcium gluconate
Sodium bicarbonate
Sodium polystyrene sulfonate
Hypertension :
Beta blockers
Calcium channel blockers
Diuretics
ARBs
ACE inhibitors.
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