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60M with pedal edema

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.








This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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 diagnosis and treatment plan


This is a case of a 60 year old male who came with complaints of

1. pedal edema since 1 week

2. tingling sensation of lower limb since 1 week

3. polydipsia since 1 week



History of presenting illness:-

Patient was apparently asymptomatic 1 week back then he developed pedal edema extending upto knee.

Tingling sensation in both the lower limbs since 1 week

Polydipsia polyuria and nocturia all are positive 

No abdominal veins dilation, vomitings, loose stools, No chest pain, palpitations, SOB, fever, cold, cough.


Past history:- 

2 years ago he had altered sensorium and diagnosed to have ?DKA, given insulin and treated.

After 10 days pt developed swelling of lower limbs and ulceration on right toe and plantar aspect of foot for which he was treated 4 months back he had altered sensorium 2⁰to hyponatremia?SIADH with pedal edema, anasarca, decreased urine output, vomiting,loose stools.

4 years back, fractured his right leg

K/c/o of DM since 10 years 

K/c/o HTN since 4 years 

N/k/c/o of asthma, TB, Epilepsy 


Personal history:

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowel and bladder: increased micturition, normal bowel movements 

No addictions and allergies


Daily routine:

Used to work as an agricultural worker, but since 4 years since he fractured his leg, he stopped working.

He wakes up at 6 am then freshens up. Then he eats breakfast at 8 am(jowar and curry). Then he sits and chats with his family members and his neighbours. 1 pm he has lunch which is similar to his breakfast. He takes an afternoon nap and then wakes up at 3 pm and then watches tv or chats with his neighbours. At 6 pm he has dinner consiting of jowar roti and sleeps at 8 pm.

 

GENERAL EXAMINATION:


Vitals :- 

Bp:- 140/90 mm hg

RR:- 20CPM

PR:- 96 BPM 

GRBS:- high


No pallor,icterus, cyanosis, clubbing, lymphadenopathy

Pedal edema is present upto knees 






 

Systemic examination :-


CVS:




Inspection:


There are no chest wall abnormalities 


The position of the trachea is central. 


Apical impulse is not observed. 


There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 




Palpation:


Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 


Position of trachea was central 


There we no parasternal heave , thrills, tender points. 




Auscultation: 


S1 and S2 were heard 




There were no added sounds / murmurs. 




Respiratory system:




Bilateral air entry is present 


Normal vesicular breath sounds are heard. 




Per Abdomen:


Shape is scaphoid


Abdomen is soft and non tender with no signs of organomegaly


Bowel sounds are heard




CNS:




HIGHER MENTAL FUNCTIONS- 


Normal


Memory intact




CRANIAL NERVES :Normal

Normal sensations felt in all dermatomes




MOTOR EXAMINATION


Normal tone in upper and lower limb


Normal power in upper and lower limb


Gait: Walks with a limp




REFLEXES


Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited


CEREBELLAR FUNCTION


Normal function


No meningeal signs were elicited


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