42year male with pedal edema and SOB
August 23, 2022
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
Our 44 yr old male patient came to the opd with chief complaints of
Decreased urine output since 1year
Pedal edema since 1year
SOB since since 9months.
HOPI:
PATIENT WAS ASYMPTOMATIC 1 YEAR BACK AND THEN DEVELOPED PEDAL EDEMA AND
WENT TO HOSPITAL AND HIS CREATININE WAS FOUND TO BE RAISED 2.1 AND HIGH BLOOD
SUGARS AND TREATED CONSERVATIVELY AND KEPT ON INSULIN SINCE THEN AND LATER
AFTER 2 MONTHS FOUND TO BE HAVING SEVERE SOB AND COVID POSITIVE AND
ADMITTED AND STAYED FOR 10DAYS AND ADVISED FOR RENAL TRANSPLANTATION BUT
THEY DENIED AND LATER AFTER 10 DAYS DEVELOPED PEDAL EDEMA AND ADMITTED IN
NIIMS HYDERABAD .AND IS ON DIALYSIS SINCE 1 MONTH WITH RIGHT FEMORAL VEIN AS
AN ACCESS FOR DIALYSIS.
Later he went to nalgonda hspl for dialysis after that he came to our hospital in January for regular dialysis.
Past history:
No similar complaints in the past
K/c/o DM since 15years.AND ON ORAL HYPOGLYCEMIC DRUGS FOR 14 YEARS AND ON
INJ HAI SINCE 1 YEAR
K/c/o HTN since 3years.
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowels:Regular
Micturition: decreased urine output
Family history:
Not significant
General examination:
Patient is c/c/c
Afebrile
Bp:110/70mmhg
PR:88
RR:14cpm
pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pedal edema present
Systemic examination:
CVS: S1 S2 sounds heard
RESP: BAE + clear
P/A : soft and non tender
CNS:NAD
Investigations:
RBS:224 mg/dl
Diagnosis:
CKD on MHD HTN /DM with recurrent acute pulmonary edema
Treatment:
O2 inhalation to maintain SpO2 >94%
Inj lasix 60mg IV BD
Tab Nicardia 20mg PO TID
Tab Arkamine 0.1mg PO TID
TAB MET XL 50MG PO OD
INJ PANTOP 4MG IV TID
TAB METALZONE 5MG PO BD
BP MONITORING 4hrly
GRBS 6hrly
Inj HAI according to GRBS
