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57 yr old male with bilateral pedal edema and decreased urine output


A 57 year old male came to OPD with complaints of bilateral leg swellings and decreased urine output

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss out 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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt

P.Navyasri 
2K18
ROLLNO-111 



A 57 year old male resident of gopalpally farmer by occupation came to OPD with
cheif complaints of
- bilateral leg swellings since 7 days 
-decreased urine output since 2 days
 -excess sweating since 4 hours . 



HISTORY OF PRESENTING ILLNESS-

-Patient was apparently asymptomatic 15 years back then developed polyuria and polyphagia and diagnosed with Diabetes mellitus and he is on oral hypoglycemic drugs . 

- 5 years back he developed right arm and leg paralysis then he was diagnosed with Hypertension and now he is on metXL- 25.

-  He had bilateral pedel edema upto knees , facial edema since 7 days

-  H/O hand swelling since 6 days
- H/O decreased urine output  and  burning micturition since 2 days
-  H/O  shortness of breath since 1 day ; which is not associated with cough , aggrevated on walking , relieved on rest.[Grade 1/2]


PAST HISTORY - 


- He is known case of Diabetes since 15 years ,
(GluconormPG1 metformin + glimiperide + pioglitazone ), 
- Hypertension since 5 years(metXL 25mg) 
- Not a known case of TB, epilepsy, asthma 
- No history of previous surgeries 





PERSONAL HISTORY -

-He wakes up at 4:30 am then he goes to his farm do agriculture work 
-Then after 1 hour he comes to home and have tea and then goes again for the work 
- then comes in the afternoon and have lunch ( rice and dal ) 
- for dinner also he will have rice 
-Appetite is decreased
- Sleep is adequate
- Bladder - decreased urine output since 2 days 
- Bowel movements - regular 
- Addictions - consumes alcohol 
  since 40years -Full bottle daily 
  Since 2 months  - quarter
  H/O smoking 25 years ago
 Presently he quitted smoking



GENERAL EXAMINATION - 

-Patient is conscious, coherent and cooperative and Well oriented with time , place and person .
-He is well built and nourished 
-No signs of pallor , icterus , cyanosis , clubbing , generalised lymphadenopathy .
-He is having bilateral pedal edema , pitting type since 7 days .


VITALS :

-Temperature : 94.6°F
-PR:102bpm 
-RR:16cpm
-BP:190/120mmhg 
-SpO2 :96%
-GRBS : 55mg%


SYSTEMIC EXAMINATION:



ABDOMEN:



INSPECTION :
Shape of abdomen- Obese.
Scar present. 
No engorged veins.
Hyperpigmented spots on Right Side of abdomen

PALPATION :
No local rise of temperature .
No tenderness .
No palpable mass.
Liver and Spleen - Not palpable .


PERCUSSION:

Normal liver span.
Tympanic note heard over stomach region .


ASCULTATION:

Bowel sounds heard.

 




CVS: 
-S1,S2 heard , 
-No murmers


RS:
-Dyspnea - grade 1 or 2 present 
-Trachea is central 
-Bilateral air entry present
-Normal vesicular breath sounds heard



INVESTIGATIONS :


8/10/22

9/10/22

PROVISIONAL DIAGNOSIS :
Acute kidney injury secondary to
  ? Diabetic nephropathy 
  ? Nephrolithiasis 
Recurrent hypoglycemia secondary to ? OHA 

Treatment:

1.Inj.25%D infusion@50ml /hr
2.IVF NS @urineoutput +30ml/hr
3.inj.LASIX 40mgIV BD
4.tab.NICARDIA 20mg BD
5.tab.ARKAMIN 0.1mg TD
6.tab.NODOSIS 500mg BD
7.tab.SHELCAL 500mg OD
8.tab.bioD3 weekly
9.tab.MET XL 25mg OD
10.inj.MEROPENUM 500mg IV/BD
11.inj.BICARB 50meq IV/BD


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