Case discussion of 56 Y/O Male with Nephrotic syndrome and Hypertension

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Case discussion of a 56 y/o Male with Ascites

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

CHIEF COMPLAINT

A 56 year old male came with complaints of Shortness of breath and abdominal distension from 2 days.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 and half months back ,then he developed pedal edema -pitting type grade 1 then gradually progressed to grade 2 over 10 days to grade 3 over 15 days
He first developed left lower limb swelling extending upto his ankle and he later gradually developed swelling of his right lower limb and the swelling in both his lower limbs extended upto his thighs
No complaints of fever, cough, burning micturition, loose stools, vomiting
No complaints of dyspnea, hematuria, frothy urine, no complaints of Chest pain, palpitations, orthopnea, PND

PAST HISTORY

H/o pulmonary koch's 22 yrs back ,used ATT for 6 months
Hypertension since 2 months

PERSONAL HISTORY

Diet : Mixed
Appetite : Reduced
Sleep : adequate
Bowel and Bladder movements : Regular
Occasional alcohol consumption
No allergies

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative
Moderately built and well nourished
Pallor : Present

Icterus : Absent
Cyanosis : Absent
Clubbing : Grade 3
Lymphadenopathy : Absent
Edema : Bilateral, pitting type upto thighs

VITALS

Temp: Afebrile

PR: 120 bpm

BP: 160/80 mmHg

RR: 24 cpm

Spo2 - 96% at RA

SYSTEMIC EXAMINATION

RESPIRATIOY SYSTEM : Normal Vesicular Breath Sounds Audible, Position of trachea is central, Bilateral decreased air entry + , Expiratory wheeze + in all areas
CVS : S1 and S2 Heard, no murmurs
CNS : Intact, Motor & sensory system: normal, Reflexes: present, Cranial nerves: intact, No meningeal signs
PA : Abdomen distended with no scars, sinuses, engorged veins , No tenderness, Percussion -, Shifting dullness + , Bowel sounds +