A 45 year old male with bilateral pedal edema

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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 a  diagnosis and treatment plan.

CASE PRESENTATION:

This is a case of a 45 year old male, gas welder and tractor driver by occupation who presented with chief complaints of :

• Swelling of both lower limbs since 4 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptotic 5 years ago then he developed grade-I shortness of breath which was insidious in onset and  gradually progressed to grade IV 6 months back. 

He has bilateral pedal edema since 4 days which is pitting type insidious in onset , aggravated on standing for long hours, relieved on taking rest. It was associated with severe knee pains since 6 months. 

He has been experiencing pedal edema on and off since 1 & 1/2 years.  

PAST HISTORY:

K/C/O : Diabetes mellitus since 6 yrs 

              Hypertension since 6 months

              Epilepsy since 1and 1/2 years

Not a known case of tuberculosis,asthma

TREATMENT HISTORY : 

FAMILY HISTORY: insignificant 

PERSONAL HISTORY:

Diet : Mixed 

Appetite:normal

Sleep : Inadequate 

Bowel and bladder: regular

 Addictions:

 Alcohol consumption since 20 years (1whisky bottle per day for 4 days in a week)

Occasional toddy consumption 

Zarda pan chewing since 6 months

GENERAL EXAMINATION:

Patient was examined in a well lit room, after taking informed consent. 

He was conscious,coherent and cooperative and well oriented to time place and person

Pallor: present

 No Icterus 

No Cyanosis:

 No Clubbing of fingers

 No koilonychia 

 No Lymphadenopathy

 Pedal edema present 

VITALS:

Temperature : Afebrile            

Pulse Rate: 75bpm

BP:

RR: 18 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard. No murmurs

RS : NVBS +, BAE +

Per abdomen: soft , non tender

CNS: HMF intact

INVESTIGATIONS:

On 18/10/2021

CUE: albumin:+ 4

               Sugar: +

               Pus cells:5-6

               Epithelial cells:3-4

               Red blood cells:nil

               Crystals and casts:nil

On 30/10/21:

Serum creatinine:2.6mg/dl 

Potassium-4.6 mmol/L

Reticulocyte count:0.6

 Hemogram:

   Hb : 8.7 gm/dl             

   TLC : 9600

   Neutrophils: 53 %

    Lymphocytes: 38%

    PCV: 24.3

    Platelets: 3.15

    LFT: 

   Total bilirubin:0.32

    Direct bilirubin:0.13

     ALT:12

     AST:15

     AKP:336

     Total protein:4.5

     A/G:0.97

   Serology: negative 

ECG:

USG ABDOMEN: 

TREATMENT: 

• Tab. Ecosprin-AV/OD/HS
• Tab. Livogen/PO/OD
• Tab NODOSIS 500mg/PO/BD
• Tab PAN 40 mg PO/OD
• Fluid restriction <2liters/day
• Tab. CEGLIM -1 PO