38/M WITH SHORTNESS OF BREATH AND PEDAL EDEMA
December 2,Friday,2022
A 38/M WITH SHORTNESS OF BREATH AND 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.
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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. 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.
MANOGYNA RAO BONTHA
ROLL NO 87
A 38 year old male resident of tummalaguda,daily wage worker by occupation,came to the OPD with
CHIEF COMPLAINTS:
-bilateral pedal edema since 15 days.
-Shortness of breath since 15 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 years ago,then he developed generalised weakness for which he visited a local hospital and got diagnosed with hypertension.He health was normal and regular and he’s been doing his regular work since 2 years.An year ago,he developed bilateral pedal edema which is pitting in type,initially till his ankles which is extending to his knees presently.
He also developed shortness of breath which was grade 2 when he noticed first during his work and progressed to grade 4 now.
PAST HISTORY:
-History of similar complaint 9 months ago,when he went to a local hospital and got diagnosed as CKD.
-History of hypertension since 3 years.
-No history of Diabetes Mellitus,Epilepsy,Tuberculosis,Asthma,CAD.
PERSONAL HISTORY:
-Patient used to wake up at 4-5 AM in the morning.
-He used to start by 6 AM from home for work.
-He usually does not carry breakfast from home,he eats breakfast,mostly idli or dosa,from a roadside breakfast stall,on his way to work.
-He is a daily wage worker at a construction site which includes strenuous physical activity.
-He comes back to home around 7-8PM in the evening.
-He eats dinner between 8.30-9.30PM.
-He goes to sleep at 9.30-11PM.
-He takes mixed diet,consumes Non-veg once or twice weekly.
-His appetite is reduced since 15-20 days because shortness of breath.He feels like shortness of breath gets aggravated during and after eating which is making him avoid food.He is eating one meal everyday since 15-20 days.
-His sleep is disturbed and he is not able to sleep because of shortness of breath.
-Bowel movements:He is able to pass stools only if he’s consuming sucralfate or milk of magnesia prescribed by physician at local hospital.
-Bladder movements-Urinates twice/thrice a day,reduced Urine output.
-Addictions-He used to consume alcohol occasionally as per the patient and his mother,but according to his wife,he consumes alcohol regularly (4-5 times a week) while coming back home from work.Patient and his mother denied if having any smoking habits,but his wife mentioned that he smokes around 4-5 cigarettes each day.History is not reliable.
-He has been consuming some OTC painkillers occasionally for post work pain since 3-4 years.
Treatment History:
-NIFEDIPINE 20mg
-METOPROLOL SUCCINATE
-TORSEMIDE 10 mg
-FUROSEMIDE 40 mg
-SODIUM BICARBONATE TABLET 500 mg
-FERROUS ASCORBATE,FOLATE,ZINC
-CLONIDINE-100 mcg
-TELMISARTAN 40 mg
-6 sessions of HEMODIALYSIS are done
-3 PRBC TRANSFUSIONS are done
FAMILY HISTORY:
Patient is hypertensive.There are no first degree relatives with hypertension.
GENERAL PHYSICAL EXAMINATION:
-Patient is conscious, coherent and non cooperative,he is well oriented to time, place, person.
-examined in a well lit area
-moderately built and moderately nourished.
-Pallor-Present
-Icterus- absent
-cyanosis-absent
-clubbing- absent
-lymphadenopathy- absent
-pedal edema- present
Skin is dry
VITALS
Temperature- 98.7 F
Pulse rate- 72 beats per min
Respiratory rate- 29 breaths per minute
Blood pressure -130/80 mm of Hg
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
INSPECTION :
-shape of chest normal
- central trachea
-abdomino thoracic type
PALPATION: -
-all inspectory findings are confirmed
PERCUSSION:
-resonant in all areas
AUSCULATION:
-bilateral air entry present
-reduced breath sounds heard.
- bilateral crackles heard.
CARDIO VASCULAR SYSTEM
S1,S2 heard no murmurs heard, JVP raised.
PER ABDOMEN
INSPECTION
-all quadrants are moving equally with respiration
-abdominal distention is present,
-umbilicus is inverted, central,
-no scars or sinuses are seen,
- no engorged veins are seen
PALPATION
- all inspectory findings are confirmed
- abdomen is soft
- non tender
- no local rise in temperature,
- no organomegaly is noticed.
PERCUSSION - dullness, fluid thrill present
AUSCULTATION - bowel sounds are not heard
CENTRAL NERVOUS SYSTEM
-no focal neurological deficits are seen.
- cranial nerve functions intact.
PROVISIONAL DIAGNOSIS:
Chronic kidney disease with hypertension
Hypertensive nephropathy
INVESTIGATION
18/11/2022
ECG
24/11/22
25/11/22
26/11/22
02/12/2022
3 December,Saturday,2022
Blood pressure recording:
12 AM-220/140
2 AM-220/140
4AM-220/150
6AM-180/100
8AM-120/70
Respiratory rate recordings:
12AM-24
2AM-24
4AM-22/150
6AM-180/100
8AM-120/70
TREATMENT PLAN :
- T.LASIX 80mg PO BD
- T.NICARDIA 20mg PO QID
- T. ARKAMINE 0.1 mg PO TID
- T. TELMIKIND 40mg PO OD
- T.PCM 650mg SOS
- T. MET XL 25mg PO OD
- SYP. SUCRALFATE 10 mL PO BOD
- SYP. LACTULOSE 20mL PO H/S
- T.DYTOR 10 mg PO BD
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