Sunday, August 21, 2022

44 yr old man with chief complaints of pedal edema since and decreased urine output

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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 Shishira Reddy
1701006005

ICU Bed 5, 44yr old man

Chief complaints:
A 44year man came with chief complaints of 
-B/L pitting type of pedal edema since 10 days , ----decreased urine output since 5 days 
- pain abdomen since 4 days 
-vomiting 1 day back

History of presenting illness:

He was asymptomatic 1 one and 1/2 yrs back , then he had swelling in face and lower limbs  and visited doctor , and was on medication . He stopped medication after 10 days. 
After few days he had difficulty in breathing (SOB grade 2) and decreased urine output 
He was admitted to hospital and was on dialysis for 2 days . 
Since then he was on dialysis twice every week. 

 Patient was apparently asymptomatic 10 days back and gradually developed B/L pitting type of pedal edema & decreased urine output. 

Pain in the epigastric region since 4 days , pricking type of pain, non radiating, aggravated after food and relieved on its own after some time .

History of vomiting of 6-7 EPISODES which was non bilious , consisted of food particles and was relieved on medication .


Past history

K/C/O HTN since 4 years  but didn't use any medication 
N/K/C /O DM ,TB , EPILEPSY, ASTHMA. 



Personal history:

Diet: mixed 
Appetite: normal 
Sleep: adequate 
Bowel n bladder: irregular , decreased urine output progressed to anuria. 
Addiction: alcohol consumption qty: 180ml  3-4 times a week at night , since 15years
And stopped since 1and 1/2 year. 
No History of smoking

 Family history: no significant history 



General examination 


Pt is concious and coherent and cooperative well oriented to time place and person, 

On examination

Pallor present( mild) , no  icterus/ clubbing/  cyanosis / lymphadenopathy /edema (apparently)
Temp: 98°F
BP : 140/100mmHg
RR: 28/min
PR : 80/min
SPO2: 99% @ RA
CVS: S1 S2 +
RS : BAE + 
CNS : NAD  
P/A  : tenderness and pain in the epigastric region 




Provisional diagnosis: ?acute gastritis
 CKD on MHD, HTN +




Investigations 

21/08/22 RFT




21/08/22 LFT



21/08/22 ABG

20/08/22 ECG



20/08/22 HEMOGRAM




20/08/22  ABG

19/08/22 SERUM ELECTROLYTES

19/08/22 TROPONIN


Plan of treatment:
1.Fluid and salt restriction
2. INJ. ZOFER 4 mg IV/ TID 
3. INJ. TRAMADOL 1 AMP in 100 ml NS IV / SOS
4. TAB. NICARDIA 10 mg PO/TID
5. TAB. ARKAMIN 0.1mg PO/BD 
6. TAB. MET- XL 25 mg PO/OD
7. TAB. SHELCAL 500mg PO/ OD
8. Cap. BIO-D3 PO/OD/WEEKLY ONCE 
9. INJ. ERYTHROPOIETIN 4000 IU S/L WEEKLY TWICE 
10. BP MONITORING 2nd hrly 
11. GRBS 2nd hrly. 

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