A Case of 40 year Old male with Swelling in both the legs
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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 a diagnosis and treatment plan.
1. Swelling in both the legs since 3 months
2.Decreased urine output since 3 months
3.Backpain since 2 months
4.Shortness of breath since 3 days
Patient used to work as a farmer and his routine includes daily physical activity about 6 am and
And does agricultural work and ended by 7pm
History of present illness
Patient was apparently asymptomatic 3 months back when he developed swelling in the legs which was Insidious in onset Intermittent i nature associated with facial puffiness .It is upto ankle level subsided on rest.
Decreased in urine output not associated with any burning micturition
Back ache was of dragging type aggravated on moderate activity relived on medication.
Shortness of breath since 3 months which was progressed from grade 3 to grade 4.He complains ofshortness of breath while walking
He was feeling cold while case taking and he complains of itching sensation over his feet .
Past history
No history of Hypertension, Bronchial asthma,Diabetes, Epilepsy.
Personal history
His appetite is normal
He takes mixed diet
His bowel and bladder movements are regular
No known allergies
Family history
Not significant
General examination
Patient is conscious coherent and coperative ill built and moderately nourished
Vitals
Temperature 98.4 F
Pulse rate 84 bpm
Respiratory rate 24 cpm
Bp 130 /70 mmhg
Spo2 98%in room air
Mild pallor
No icterus
No cyanosis
No clubbing
SYSTEMIC EXAMINATION
Systemic examination:-
-CVS
S1 and S2 are heard
no thrills and no murmurs
-Respiratory
vesicular breath sounds heard
trachea is in central position
no wheezing
Dyspnoea-grade 4.
-Abdomen
obese shaped abdomen
no tenderness
no palpable mass
no hernial orifices
no free fluid
liver and spleen are not palpable
bowel sounds are heard
-CNS
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
Investigations
Usg
On 26/10/2021
1.Fluid restriction less than 1.5 lit per day
Dialysis started on 15/10/21
4 session of HD done
Salt restriction less than 2gm per day
Tablet lasix40 mg po bd
Tab Nodosis 500 mgPo bd
Tab shelcal
Tab Bio D3
Tab Orofer po od
Inj erythropoietin 4000Iu sc weekly once
On 27 10 21
1.Fluid restriction less than 1.5 lit per day
Dialysis started on 15/10/21
4 session of HD done
Salt restriction less than 2gm per day
Tablet lasix40 mg po bd
Tab Nodosis 500 mgPo bd
Tab shelcal
Tab Bio D3
Tab Orofer po od
Inj erythropoietin 4000Iu sc weekly once
On 28 10 21
1.Fluid restriction less than 1.5 lit per day
Dialysis started on 15/10/21
4 session of HD done
Salt restriction less than 2gm per day
Tablet lasix40 mg po bd
Tab Nodosis 500 mgPo bd
Tab shelcal
Tab Bio D3
Tab cetrizine po tid
Syrup benadryl 5 ml tid
Tab Orofer po od
Inj erythropoietin 4000Iu sc weekly once
Provisional diagnosis
Chronic kidney disease on hemodialysis.
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