76 YEAR OLD MALE WITH PEDAL EDEMA AND DIABETES MELLITUS SINCE 15 YEARS
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This Elog also reflects my patient centered online learning portfolio.
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.
Clinical pictures:
76 year old male farmer by occupation came with chief complaints of
Pedal edema since 20 days
History of present illness
Patient was apparently normal
15 years ago he sustained an injury for right leg while working with tractor for which he developed ulcer and was hospitalized for 1 week while then he was diagnosed with Diabetes mellitus on medication.(Metformin 500 mg OD)
3 years ago he developed Blurring of vision in right eye undergone cataract surgery.
3 months ago he developed Blurring of vision in left eye.
25 days ago he developed abdominal distension.
20 days ago patient developed pedal edema in both limbs which was insidious in onset which is of pitting type extending upto the knee.
He went to the local hospital and undergone some blood investigations was given some medication.(Details not known)
Pitting type of edema aggrevated by walking relieved on lying down.
Patient complains of tingling and burning sensation and sobgrade 2 occasionally
No c/o decreased urine output,orthopnea,PND,facial puffiness
Daily routine
Patient is a farmer used to go for agricultural work currently stays at home.
He wakes up at around 6 am takes a cup of tea at around 8:30 am then eats roti forbreakfast by 9 pm.
He takes a cup of rice and dal for lunch around 12 30 pm
He takes a nap in the afternoon at 2pm talks to his friends after which he goes outside for walking for 1 hour.
He comes back home and completes his dinner by 9pm and goes to bed by 10pm.
His diet includes roti and curry for breakfast, Rice and dal for lunch,rice and dal for dinner.
PAST HISTORY:
No H/o similar complaints in the past
Not a known case of Hypertension ,TB,Bronchial Asthma,thyroid, CAD.
SURGICAL HISTORY:
Undergone cataract surgery for right eye 3 years ago
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep:Adequate
Bowel and bladder movements: Regular
Allergies:No
Addictions:No
Stopped alcohol 20 years ago
FAMILY HISTORY:
No H/o Similar complaints in the family.
PHYSICAL EXAMINATION:
Patient is conscious coherent and cooperative
Moderately built and moderately nourished
Well oriented to time place and person
VITALS
TEMPERATURE:Afebrile
Pulse rate: 89bpm
BP: 130/90 mmhg
No Pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
SYSTEMIC EXAMINATION:
ABDOMEN EXAMINATION:
Shape of abdomen: Distended
No tenderness
No palpable mass
Dull on Percussion
CNS EXAMINATION
No focal neurological deficit
CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers heard.
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular breath sounds heard
Trachea: central
Investigations:
CUE
Serum creatinine 
Serum electrolytes 
Treatment:
1.Inj Human Actrapid insulin s/c TID Before meals According to GRBS
2.Tab Lasix 20 mg PO/BD
3.Tab Neurobion forte PO/OD
4.GRBS 7 . Monitoring
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