General medicine final year practical examination

58 year old male with Pedal edema.

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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 I reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Short case

S.Neeraja Reddy

H.tno 1701006170

58 year old farmer by farmer byoccupation resident of suryapet  came with chief complaints of 

Edema in both the legs since 5 days

History of present illness 

Patient was apparently asymptomatic 5 days ago where he developed pedal edema in both the limbs pitting type which was Insidious in on set gradually progressive. 

No aggrevating or relieving factors.

10 days ago he went to one hospital due to  sob grade 4  and underwent 2 sessions of dialysis.

History of 2 blood transfusions. 

No history of burning micturition, no urinary disturbances 

No history of fever chills or rigors.

No history of NSAIDS abuse.

Past history 

No history of Hypertension Diabetes Bronchial Asthma Epilepsy thyroid tuberculosis 

Family history 

Not relevant 

Personal history 

He takes mixed diet

Appetite normal

Bowel and bladder movements are regular 

Non smoker

occasional alcoholic

No known allergies 

Clinical images

Pitting edema

GENERAL EXAMINATION 

Patient is conscious coherent and coperative well oriented to time place and person. 

Vitals 

Afebrile

BP 110/70mmhg

PR 90bpm

Respiratory rate 18 cpm

Mild pallor

Icterus Cyanosis Clubbing Lymphadenopathy 

 Bilateral pedal Edema  pitting type upto ankle

SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION 

INSPECTION:

•Shape – scaphoid

•Flanks – free

•Umbilicus –central in position , inverted.

•All quadrants of abdomen are moving equally with respiration.

•No dilated veins, hernial orifices, sinuses

•No visible pulsations.

 PALPATION:

•No local rise of temperature and tenderness

•All inspectory findings are confirmed.

•No guarding, rigidity

•Deep palpation- no organomegaly.

 PERCUSSION:

•There is no fluid thrill , shifting dullness.

Percussion over abdomen- 

tympanic note heard.

 AUSCULTATION:

 Bowel sounds are heard.

CARDIOVASCULAR SYSTEM

INSPECTION:

•Chest wall - bilaterally symmetrical 

•No dilated veins, scars, sinuses

PALPATION:

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

•No parasternal heave, thrills felt

 AUSCULTATION:

•S1 and S2 heard , no added thrills and murmurs heard.

 RESPIRATORY SYSTEM 

INSPECTION:

•Chest is bilaterally symmetrical

•Trachea – midline in position.0

•Apical Impulse is not appreciated 

 •Chest is moving normally with respiration.

•No dilated veins, scars, sinuses.

PALPATION:

•Trachea – midline in position.

•Apical impulse is felt on the left 5th intercoastal space.

•Chest is moving equally on respiration on both sides

•Tactile Vocal fremitus - appreciated 

 PERCUSSION:

The following areas were percussed on either sides- 

• Supraclavicular-resonant

•Infraclavicular- resonant

•Mammary- resonant

•Axillary- resonant

•Infraaxillary- resonant

•Suprascapular- resonant 

•Infrascapular- resonant 

• interscapular - resonant.

 AUSCULTATION:

•Normal vesicular breath sounds heard 

•No adventitious sounds 

 

CENTRAL NERVOUS SYSTEM EXAMINATION.

 HIGHER MENTAL FUNCTIONS:

•Patient is Conscious, well oriented to time, place and person.

•All cranial nerves - intact

•Motor system: Intact

•Superficial reflexes and deep reflexes are present , normal

•Gait is normal

•No involuntary movements

•Sensory system - 

-All sensations pain, touch,temperature, position, vibration, are well appreciated.

Investigations

 Hiv test 

Hiv non reactive

Random blood sugar

RBs 126 mg / dl

Hbs Ag negative 

Renal function tests

Urea 138 mg /dl

Creatinine 7.2 mg/dl

Uric acid 10.9  mg/dl

Hemogram

Hb 7.3 gm /dl

Rbc 2.51 mill

Serum iron

Serum iron 63 ug/dl

Liver function tests

SGOT 43 IU/L

Alp raised 325 iu /dl

Albumin 3.38 gm /dl

Complete urine examination 

Usg 

Bilateral grade 2  to3 RPD with simple renal cysts

PROVISIONAL DIAGNOSIS 

CHRONIC KIDNEY DISEASE ON dialysis 

Treatment 

1.Tab Lasix 40mg BD

2.Tab Pantop 40 mg /po/OD

3.Tab Nodosis 500mg BD

4.Tab Orofer XT Po/OD

5.Cap Bio D3 /po weekly once

6.Inj Erythropoietin 4000 U s.c weekly once 

7.Tab Nicardia 5mg /sos