60Yr Male with pedal edema and tingling sensation of lower limbs

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

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

Pedal edema since 1 week

Tingling sensation of lower limb since 1 week

Excessive thirst since 1 week 

History of presenting illness:-

Patient was apparently asymptomatic 1week back then he developed pedal edema which is pitting type extending upto knee. Aggravated on walking and relieved on taking rest.

Tingling sensation in both the lower limbs since 1 week.

Polydipsia,polyuria and nocturia present.

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 upto knee and ulceration on right toe and plantar aspect of foot for which he was treated.Four months back he had altered sensorium secondary to hyponatremia ?SIADH with hypokalemia.2 months back he again got admitted with pedal edema, anasarca, decreased urine output, vomiting,loose stools.

4 years back, Right lower limb was fractured.

K/c/o of DM since 18 years 

K/c/o HTN since 4 years 

N/k/c/o of asthma, TB, Epilepsy,CAD,CVA.

Personal history:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder: increased micturition(since 1week), normal bowel movements 

No addictions and allergies

Daily routine:

He was an agricultural worker, but since 4 years he fractured his leg(fall of tree on his leg) and 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

Mild pallor present,No icterus, cyanosis, clubbing, lymphadenopathy. 

Systemic examination :-

CVS:

Inspection:

No chest wall abnormalities  

Trachea is central. 

Apical impulse is not observed. 

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 

No parasternal heave , thrills, tender points. 

Auscultation:

S1 and S2 heard 

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

DIAGNOSIS : 

HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .

INVESTIGATIONS : 

29/4/23