Case-1 SOB AND PEDAL EDEMA

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

CASE

56 year male farmer, No history of Smoking or Alcohol consumption.

Patient was apparently asymptomatic 2 months back, then he developed pedal edema Grade-I which gradually progressed to Grade-II over 10 days and to Grade-III in next 15 days.

Patient came to Casualty with S.O.B since 2 days.

PAST HISTORY

H/O- Pulmonary TB 22 yrs back used Anti-tubercular treatment ( ATT)  for 6 months.

GENERAL EXAMINATION

• Pallor : Yes
• Icterus: No
• Cyanosis :no
• Clubbing of fingers/toes : Yes
• Lymphadenopathy : No 
• Edema of feet : Yes
• 
  
  
  
• Malnutrition : No
• Dehydration : No
• Temp. : Afebrile
• P.R.  : 120 bpm
• R.R. :  16 cpm
• B.P.   :  160/80 mm/hg
• SPO2 at room Air : 96%

SYSTEMIC EXAMINATION

CVS 

• Cardiac sounds      :- S1 & S2 - Present
• Cardiac murmurs   :- NO 

RESP. SYSTEM

• Dyspnoea  :Yes
• Wheeze    :Expiratory wheeze presenting in all areas.
• Position of Trachea : Central
• Breadth Sounds : Vesicular

ABDOMEN

• Shape of abdomen : Distended 
• Tenderness : NO
• Palpable Mass : NO
• Liver : Not Palpable
• Bowel sounds: Yes

C.N.S

• Level of consciousness : Consciousness: Conscious / Alert 
• Speech : Normal
• Signs of Meningeal irritation   a)Neck stuffiness: NO  b)Kernig's sign: NO
• Cranial nerves- Normal
• Motor system - Normal
• Sensory nerves- Normal
• Glasgow Scale - 15/15
• 
  
  
  
  

TEST REPORTS

1. RETICULOCYTE COUNT

2. SAAG (serum-ascites albumin gradient)

3.ASCITIC FLUID FOR LDH

4. SERUM LDH

5. BLOOD UREA

6.URINE PROTEIN/CREATININE RATIO

7. CUE ( COMPLETE URINE EXAMINATION )

8. HEMOGRAM 

9.SERUM ELECTROLYTES ( Na, K , CL )

10. SERUM CREATININE 

11.ULTRASOUND REPORT

Disscusion :

General examination of the patient tells us that patient is c/c/c   and in a hypertensive state

Systemic examination tells us that he  has a distended abdomen.

Test results:-       

• Reticulocyte Count:- Normal
• SAAG :-  1.55 (Normal range<1.1)
• LDH in ascitic fluid :- Lowered
• Serum LDH :- within the Normal range
• Blood Urea :- Elevated -19 mg/dl ( Normal Range 12-42 mg/dl)
• Urine protein levels :- +++ 
• Urine protein/ Cretinine ratio :- 2.76 (196/70)
• Hemoglobin :- 5.4 gm/dl
• RBC count :- 2.34 million/cumm (Normal 4.5-5.5 million/mm^3)

Provisional Diagnosis: 

Nephrotic Syndrome with Hypertension and anemia due to decreased erythropoietin secretion

MEDICATION ADMINISTERED;

Acknowledgments:

I would like to thank Dr. Shruti Mohanty ( Principal, Kamineni institute of Medical sciences) for providing me with opportunity .

I would like to thank Dr. Rakesh Biswas sir ( HOD G.M.)  and all other Faculty, staff and my colleagues who guided and helped me with this case history and diagnosis.

Reference:

Edema Grading :-https://images.app.goo.gl/CPsXaSSp7TQGvoNa7

Glasgow scale :- https://images.app.goo.gl/FKenADGMDV5UU1uA8