58 year old male with pedal edema




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.

58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 15 days, worsened 3 days back, facial puffiness since 1 week

History of Present illness - 
Patient was apparently asymptomatic 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive 

2 years back Pt developed  pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months . Swelling in the left chest region, gradually progressing to current size, since 4 months
Back pain since 2 months

7 days back - developed Facial puffiness
Shortness of breath since 7days

Grade II-III progressed to Grade IV since 15 days along with orthopnea 

No c/o palpitations, giddiness, cold, cough, burning micturition


PAST HISTORY -

Known case of Hypertension since 4years on Tab nifedipine 10mg OD
Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history
Appetite- normal

Diet- mixed

Bowel movement- Regular

Alcoholic stopped 4 yrs ago

Non smoker


On examination

Pt is C/c/c

No Pallor,Icterus,Cyanosis,Lymphadenopathy

Edema of feet + 


Vitals
Pr:82/min

Bp:140/90

Spo2:98%

Temp - Afebrile



Systemic examination

CVS - S1,S2 +

CNS - NAD

P/A- Soft, non tender


Investigations

Serology - Negative

Provisional Diagnosis -CKD
Treatment-
Fluid restriction (<1l/day)

Salt restriction (<2g/day)

T· LASIX 40 mg PO BD

T. Nicardia 100mg PO BD

T. NODOSIS 500 MG PO BD

T. OROFER-XR PO OD

T. SHELCAL-CT PO OD

CLINICAL IMAGES

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