65 y old male with sob,pedal edema,lower back pain

July 03, 2023

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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.

Name: P.Nikitha

Roll no: 102

65 y old male daily wage labourer by occupation came to opd with chief complaints of

Bilateral swelling of limbs since 1 month

Lower back pain since 1 week

Shortness of breath since 4 days

History of presenting illness:

Patient was apparently asymptomatic

10 years back

He had a history of trauma 10 years back in his lumbar region

Since then he had back pain,pricking type

For which he used medication.

He was also using a belt for support to spinal cord since past 3 months.

Since past 1 week

His back pain got aggravated radiating from right lumbar region to lower limbs which is not relieving on medication.

Pitting type of edema is seen in lower limbs upto knee. Which caused difficulty in climbing stairs.

Shortness of breath (grade 3) aggrevated on walking and relieved on resting

Past history :

Known case of hypertension since 5 months which was diagnosed during hospital visit

Where he went with complaints of neck pain,sweating,fever.

Not a known case of diabetes ,asthma,epilepsy,tuberculosis.

Personal history:

Mixed diet

Appetite: reduced

Reduced bowel movements

Normal bladder movements

Sleep disturbed due to pain

Addictions:

Daily routine :

Before 10 years:

He used to wake up at 6 AM and has his breakfast and goes to work (labour - lifting 100 kg rice bags on his back) and then has his lunch and works until 4 and then he used to drink and works again until 8 pm and returns home and used to had dinner and sleep by 10 pm

Now:

He wakes up at 5 AM and gets freshened

He will have tea and then breakfast by 8 AM and then watches tv and phone and then eats lunch at 1 pm and then sleeps until 3 pm . After having dinner he will sleep by 9 pm

Family history:

Not significant

General examination:-

Patient was conscious,coherent,well oriented to time and place

No pallor,icterus,cyanosis ,clubbing,lymadenopathy

Bilateral pitting type pedal edema is present