60 M presented 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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

This is a case of a 60 year old male who came with complaints of

1. pedal edema since 1 week

2. tingling sensation of lower limb since 1 week

3. polydipsia since 1 week

History of presenting illness:-

Patient was apparently asymptomatic 1 week back then he developed pedal edema extending upto knee.

Tingling sensation in both the lower limbs since 1 week

Polydipsia polyuria and nocturia all are positive 

No abdominal veins dilation, vomitings, loose stools, No chest pain, palpitations, SOB, fever, cold, cough.

Past history:- 

2 years ago he had altered sensorium and diagnosed to have ?DKA, given insulin and treated.

After 10 days pt developed swelling of lower limbs and ulceration on right toe and plantar aspect of foot for which he was treated 4 months back he had altered sensorium 2⁰to hyponatremia?SIADH with pedal edema, anasarca, decreased urine output, vomiting,loose stools.

4 years back, fractured his right leg

K/c/o of DM since 10 years 

K/c/o HTN since 4 years 

N/k/c/o of asthma, TB, Epilepsy 

Personal history:

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowel and bladder: increased micturition, normal bowel movements 

No addictions and allergies

Daily routine:

Used to work as an agricultural worker, but since 4 years since he fractured his leg, he stopped working.

He wakes up at 6 am then freshens up. Then he eats breakfast at 8 am(jowar and curry). Then he sits and chats with his family members and his neighbours. 1 pm he has lunch which is similar to his breakfast. He takes an afternoon nap and then wakes up at 3 pm and then watches tv or chats with his neighbours. At 6 pm he has dinner consiting of jowar roti and sleeps at 8 pm.

 

GENERAL EXAMINATION:

Vitals :- 

Bp:- 140/90 mm hg

RR:- 20CPM

PR:- 96 BPM 

GRBS:- high

No pallor,icterus, cyanosis, clubbing, lymphadenopathy

Pedal edema is present upto knees 

 

Systemic examination :-

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

Respiratory system:

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

Per Abdomen

Shape is scaphoid

Abdomen is soft and non tender with no signs of organomegaly

Bowel sounds are heard

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Gait: Walks with a limp

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited