A 63 yr old male with Pedal edema and shortness of breath

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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

A 63 yr old male came to opd with chief complaints of

   Pedal edema since 1 yr 

   Shortness of breath since 1 month

History of presenting illness:

Patient was apparantly asymptomatic 12 yrs back then he developed shortness of breath which is of grade 4 and lost his consciousness.For which he was admitted in hospital and undergone coronary artery bypass graft surgery and was also diagnosed with hypertension and diabetes.

Thereafter 1 yr back he started developing bilateral pedal edema which is of pitting type for which he went to hospital and was diagnosed with chronic kidney disease (undergone 5 times dialysis)

1 month back he developed shortness of breath (grade 4) and bilateral pedal edema which is of pitting type.

It was associated with cough.

No history of fever, cold

No history of palpitations,sweating

No history of chest pain, orthopnea ,PND

No history of abdominal pain and abdominal distension 

No history of decreased urine output, burning micturition 

No history of nausea , vomiting,headache and giddiness 

 Past history:

K/c/o DM since 12 yrs (Tab.linagliptin)

K/c/o HTN since 12 yr(Tab.CARCA-6.25)

Previous surgery for CAD -CABG surgery done 12 yr back

Not a k/c/o Asthma, TB , Epilepsy, Thyroid disorders 

Family history:

No significant family history

Personal history:

Diet : vegetarian

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

No addictions

No drug or food allergies 

General examination:

Patient is concious coherent and cooperative

Moderately built and nourished

Temperature: afebrile

Pulse : 95bpm

RR: 15 cpm

BP: 130/80 mmHg

Pallor present

Icterus - absent

Cyanosis- absent

Clubbing - absent

Lymphadenopathy- absent

Bilateral pedal edema is present (pitting type)

Systemic examination:

CVS:

Jvp not raised 

Inspection:

Shape of chest - elliptical

No visible pulsations

Midline scar is seen (done for coronary artery bypass graft surgery)

No engorged veins 

Apical impulse not visible

Palpation:

Apex beat present over the left 5th intercostal space medial to midclavicular line

No parasternal heave

No precordial thrill

No dilated veins

Auscultation:

S1 S2 heard ,No murmurs 

Respiratory system:

Upper respiratory tarct - normal

Lower respiratory tract:

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- central

Midline scar is seen

Palpation:

Trachea is central

Normal chest movements

Vocal fremitus is normal in all areas except in inframammary region on both sides it is decreased( in sitting position)

Percussion: in sitting postion

                                                 Rt.                          Lt

Supraclavicular.                 N(resonant).          N

Infraclavicular.                   N.                             N

Mammary region.               N.                             N

Inframammary region.      Dull.                       Dull

Axillary region.                  N.                              N

Infra axillary region.          N.                            N

Supra scapular region.         N.                          N

Interscapular region.             N.                          N.  

Infrascapular region.             N.                           N

Auscultation:

Normal vesicular breath sounds

Crepts are heard in infraaxillary area(in supine postion)

Vocal resonance is normal in all areas except it is decreased in inframammary region of both sides(in sitting position)

Per Abdomen:

Inspection:

Shape - flat

Flanks - free

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations

Hernial orifice are free

 

Palpation:

No local rise of temperature

Abdomen is soft and non tender

No palpable spleen and liver

No other palpable masses

Percussion:

Resonant.

Auscultation:

Normal bowel sounds heard

CNS :

Higher motor functions - intact

Cranial nerves - intact

Motor system:

             Rt- UL.     LL.                Lt- UL.        LL

Bulk  - normal    N.                         N.           N 

Tone -     N.           N.                         N.           N

Power - 5/5.          5/5.                      5/5.         5/5

Reflexes:         

                             UL.                            LL

Biceps.                 2+.                            2+

Triceps.                2+.                           2+

Supinator.            2+.                           2+

Knee                      2+.                            2+

Ankle.                    2+.                            2+

 Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation 

Investigations:

Provisional diagnosis:

CKD on MHD