35 year old man with pedal edema and facial puffiness

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

 Here we discuss our 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 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 35 year old male who is a tractor driver from yadadri came with

CHIEF COMPLAINTS :

- Pain abdomen since 4-5 days

- Nausea and vomiting since 3 days

- Shortness of breath since 3 days

HISTORY OF PRESENT ILLNESS :

- Patient was a symptomatic 4 months back and developed bilateral pitting type of pedal edema with facial puffiness for which he went to the local hospital and tests were done 

- Baseline creatinine was 4.9 and blood urea was 44 Hypertension was diagnosed.(180/90 mmHg)

- The bilateral pitting type of pedal edema was relieved 1 week ago 

- Patient developed dragging type of diffuse pain in abdomen from 4-5 days gradual in onset and progressive in nature with no aggregating or relieving factors

- Nausea and vomiting since 3 days food is content 

- Didn't pass stool since 3 days 

- No bletching

- Fullness of stomach and SOB grade 3 were also felt by him.


PAST HISTORY :

Diabetes - No

Hypertension - Yes

- Since 4 months was on regular medication.

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - Nil


FAMILY HISTORY : Nil significant 


PERSONEL HISTORY :

Diet - Mixed

Appetite - Normal

Bowel movements - No stools since 3 days

bladder movements - Normal

Allergies - No

Addictions - Consumption of alcohol daily 90 ml since 2 years.


GENERAL EXAMINATION :

Temperature -  Afebrile

Pulse - 78 beats/min

BP - 180/120 mmHg

RR - 18 cycles/min

SPO2 - 98 %

Pallor - No


Icterus - No


Clubbing - No

Cyanosis - No

Lymphadenopathy - No


SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular


ABDOMEN : Soft

Shape - Scaphoid

No palpable mass

Umbilicus everted


Tenderness present 

No guarding or Rigidity

Fluid thrill and shift in dullness present 

Bowel sounds heard


CNS : Normal

- Patient is Conscious, Coherent well oriented to surroundings.


REFLEXES : Normal


INVESTIGATIONS :

3/8/22 -


















4/8/22 -






5/8/22 -






6/8/22 -





7/8/22 -




Analysis of abnormal investigations -



PROVISIONAL DIAGNOSIS :

CRF with HTN

? Acute Gastritis

Hyponatremia with decreased evaluation.


TREATMENT :

4/8/22


5/8/22 -




5/8/22




6/8/22





7/8/22













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