MBBS part-2 Final examination case discussion

                           SHORT CASE


A 57yrs old male patient with bilateral pedal edema

ROHITH SOMANI
Reg no:1701006172

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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.

Chief complaints::

57yrs old male patient came with complaints of bilateral pedal edema since 5 days and decreased urinary output since 2 days

History of present illness:

Patient was apparently asymptomatic 7months back the he developed edema in both the legs which was insidious in onset and gradually progressive 
Edema is of pitting type
There is no associated shortness of breath

History of past illness:

Patient is known case of hypertension since 1month
Not a known case of diabetes, epilepsy,TB,CAD,asthma.

Treatment history:

On anti-hypertensive medication since 1 month

Personal history;

Diet - mixed 
Appetite-normal
Bowel and bladder-regular
Sleep-adequate
No history of any allergies
Addictions- alcohol consumption occasionally

Family history

No history of similar complaints in family members.

General examination

The patient is conscious coherent and cooperative, well oriented to time place and person

Moderately built and moderately nourished
Pallor- present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal Edema -present
Vitals:
Temperature:98.8degree F
PR:90bpm
Respiratory rate:18cpm
BP:135/90mm hg
Spo2:97%


Systemic examination:

Cvs:::

S1,s2 heard
No murmurs
No thrill

Respiratory system::

Inspection::

Shape of chest ::bilaterally symmetrical
No scars and sinus on Chest
No drooping of shoulder

Palpation::
 Inspectory findings confirmed
Apex beat felt at5th IC space medial to midclavicular line 

Percussion;;

All areas of percussion are normal

Auscultation::
Normal vesicular breath sounds heard

Abdomen examination:

Shape of abdomen-scaphoid
Tenderness-absent
Palpable mass-absent
Hernial orifices- normal
No free fluids
No bruits
Liver-palpable
Spleen-not palpable
Bowel sounds-pesent


CNS....

Conscious
Speech normal 
Neck stiffness.no
Kernigs sign.no


Sensory system:intact
Motor system:::
Reflexes..normal
Power of LL,uL...5/5

Investigations:

2D echo:all the valves are normal 
All chambers are normal
No RWMA is seen

ECG:


Provisional diagnosis:
Chronic kidney disease on maintenance hemodialysis

Treatment:
Tab.Lasix-40mg/bd
Tab.PAN-40mg/od
Tab.Nodosis-500mg/bd
Tab.orofer-xt od
Cap.BIO-D3/weekly once
Inj.Erythropoietin 4000IU/weekly once
Tab.Nicardia
Monitor vitals.



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