A 49 year old presented with lower limb swelling.
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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 an a 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.
Maheshwari Jagathkari
Roll no. 57
Case report
A 49 year old male presented with cheif complaints of
Lower limb swelling since 10 days
Fever since 5 days
History of present illness
Patient was apparently asymptomatic 6 years back then he noticed a progressive swelling of right limb and then was diagnosed with filariasis.
3 years back patient had pedal edema and on further evaluation was diagnosed with chronic renal failure.
2 years back patient had COVID infection following which he developed shortness of breath at rest following which he went to a corporate hospital and was diagnosed to have Myocardial Infarction and was treated with thrombolysis with STK (streptokinase-injection, Kabikinase, Streptase).
He was also diagnosed with renal failure.
1 month later to this coronary artery angiography was done and right coronary artery was recanalized.
Later he had many such episodes of grade 4 Shortness of breath and diagnosed with severe heart failure.
10 days back he noticed a swelling on right dorsum of foot which gradually progressed to current size of approximately 4cm in length and 3cm in breadth.The swelling is associated with pain and fever since 5 days.
No blisters seen
No local rise of temperature.
Past history
He is a known case of diabetes and hypertension since 12 years and is on regular medication.
History of CAD 2 years back.
He has no history of asthma, tuberculosis.
Family history
No similar complaints in the family members.
Personal history
Patient takes a mixed diet with normal appetite and regular bladder and bowel movements with adequate sleep.
Addictions
Patient started alcohol abuse when he was 20 years old and stopped taking alcohol since last 5 years.
No known drug allergies
General examination
Patient is concious, coherent, coperative; well oriented to time, place and person; moderately built and nourished.
Pallor, pedal edema -present
No signs of icterus, cyanosis, clubbing, generalized lymphadenopathy are seen.
Vitals
BP: 130/90mmHg
Pulse rate:76bpm
RR:16cpm
Temperature:Afebrile.
Systemic examination
CVS- S1 and S2 heart sounds heard.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
Per abdominal examination revealed soft non tender abdomen.
No focal neurological deficits noted.
Limb examination
A swelling is present over the right dorsum of foot of size 4*3cm extending from the from the fingers to 1-3 cm below the knee.No blisters are seen.
Provisional diagnosis
Right foot cellulitis with acute kidney injury
Chronic kidney disease
Coronary artery disease
Investigations.
Nick's given on the swelling to drain out the collection.
Aspectic dressing done.
Compression crepe bandage applied.
Hemodialysis done 3 cycles
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