50 YEAR OLD MALE WITH SWELLING OF UPPER AND LOWER LIMBS.

SUDHAMSHI REDDY

 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 

50 year old male came with complaints of swelling of upper and lower limbs since 5-6months.

HOPI:

Patient was apparently asymptomatic  5-6months back then he developed

- swelling of body, facial puffiness, swelling of hands, swelling of legs- insidious in onset, gradually progressive

- swelling of both lower limbs- pitting type, extending upto knee, aggravated on sitting/walking, relieved on lying down.

-Patient complaints of reduced urine output since 10 days

 associated with burning micturition.

- C/O fever since 10 days low grade, intermittent associated with chills and rigors, relieved on taking medication.

-C/O SOB- grade 2 since 10 days, relieved on rest.

-No h/o pain abdomen, abdomen distension, chest pain, palpitations, no orthopnoea, PND.

PAST HISTORY:

K/C/O DM2 since 10 years, on medication( Tab. Metformin 500mg BD)

K/C/O HTN since 5 years, on Tab. Amlodipine 10mg OD

K/C/O Epilepsy since 2 years, on Tab Levipil 750mg OD

K/C/O CAD since 2 years, on Tab Clopidogrel OD

Not a K/C/O TB, CVA, Thyroid disorders, Asthma.

PERSONAL HISTORY:

Diet mixed

Sleep normal

Regular bowel and bladder habits

Alcoholic, stopped 2 years back.

Smoker, stopped 2 years back

No significant family History

GENERAL EXAMINATION:

O/E 

Patient is conscious coherent cooperative

Afebrile on touch

PR : 84bpm

RR : 16cpm

BP : 140/80 mm of hg

Grbs :119 mg/dl

SYSTEMIC EXAMINATION:

RS: BAE , NVBS no added sounds

CVS : S1 S2 heard no murmurs

P/A : soft , non tender

CNS : higher mental functions intact

Tone normal in all 4 limbs

Power 5/5 in all limbs

All reflexes present.

INVESTIGATIONS:

Hb- 8.9gm/dl

TLC- 5200cells/cu.mm

PLT- 3.43 lakhs/cu.mm

CUE:

Albumin: present(3+)

Pus cells: 3-4

Epithelial cells: 2-3

RBS: 131mg/dl

Na- 140mEq/L

K- 6mEq/L

Cl-108mEq/L

Ca- 1.20mmol/L

Serum creatinine- 1.7mg/dl

Blood urea- 69mg/dl

USG ABDOMEN:

1. GB wall edema

2. Minimal ascites

3. B/L pleural effusion-S/o polyserositis

4. Grade I RPD changes in B/L kidneys

5. Mild bladder wall thickening? Cystitis.

ECG:

PROVISIONAL DIAGNOSIS:

HYPERKALEMIA SECONDARY TO ?ACUTE RENAL FAILURE.

FEVER UNDER EVALUATION 

K/C/O DM2, HTN, CAD.

TREATMENT:

1. INJ HAI S/C premeal /TID

2.Tab. NICARDIA 10mg PO/OD

3.Tab. ECOSPIRIN- AV(75/10) PO/HS

4. Nebulisation with SALBUTAMOL 2 RESPULES  

   EVERY 4th HOURLY

5. Tab. LASIX 40mg PO/BD.