60 year old male with pedal edema

August 11th 2022

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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.

A 60 yr old male patient, construction worker by occupation and a resident of suryapet came with chief complaints of pedal edema since 1 month.

History of presenting illness:

 Patient was apparently asymptomatic 2 years back.

Then he went to local hospital and diagnosed with diabetes since 2 years.He is using medications for diabetes.

Then after an year he went to local hospital and diagnosed with hypertension.

Since one year he developed pain in both the lower limbs and using NSAIDS since then.

Now 1month back ,he developed pedal oedema and also loin pain.

He also had decreased urine output,breathlessness and burning micturition.

Since 2 weeks he had decreased appetite,low grade fever and generalized weakness.

No history of facial puffiness.

Past history:

He is known case of diabetes since 2 years and hypertension since 1 year.

Personal history:

Loss of appetite

Bowel: regular

Micturition: normal

No allergies

Had habit of alcohol but stopped since 5 months.

Family history:

Not significant

General examination:

Patient was conscious, coherent, cooperative and well built and nourished 

No pallor,clubbing, cyanosis,icterus, generalized lymphadenopathy

Bilateral pedal oedema present of pitting type.

Vitals:

Temp:afebrile

Pulse:82bpm

Respiratory rate:14cpm

Blood pressure:120/70 mm Hg

Systemic examination:

Cardiovascular system:S1, S2+ and no murmurs are heard.

Respiratory system: normal vesicular breath sounds are heard

Central nervous system: no functional deficits

Abdomen: 

no tenderness,no palpable mass

Investigations:

Provisional diagnosis:

CRF on medical management 

Treatment:

Salt and fluid restriction

Tab.Nicardia 20 mg per oral/BD

Tab.Lasix 40 mg per oral/BD

Cap Bio D3 weekly per oral 

Tab .Nodosis 500 mg per oral/ BD

Syp.Aristozyme 15 ml per oral/TID