70yr old male with B/L pedal oedema and SOB

 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the 

 -This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

-Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". 

-This E log book also reflects my patient-cen
tred online learning portfolio and your valuable comments on comment box is welcome. 
C Preetham Reddy
Roll no 25



CHIEF COMPLAINTS: 
Shortness of breath since 2 weeks
Bilateral pedal oedema since 2 weeks
decreased urine output since 12 days


HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 weeks back then he developed bilateral pedal oedema(which was gradually progressive and of pitting type) up to knee joint.
He developed Shortness of breath 12 days ago which  progressed gradually from grade 2 to grade 4
He

. No history of fever
. No history of burning micturition
. No history of loose motions

HISTORY OF PAST ILLNESS:
 K/c/o hypertension since 10 years N/k/c/o:DM,ASTHAMA,CAD,EPILEPSY,HYPOTHYROID,

TREATMENT HISTORY:

PERSONAL HISTORY:
. Diet: mixed
. Appetite : Reduced
. Micturition: normal
. Bowel and bladder movements: regular
.Addictions: occasional drinker, 












ON EXAMINATION

Patient is conscious ,coherent and cooperative
well oriented to time,place and person .

Pallor  - present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Koilonychia - absent

Lymphadenopathy - absent

Edema - Bilateral pedal odema 


Temperature- Afebrile
Pulse rate- 82 b/m
Respiratory rate- 16 cpm
Bp- 142/80 mmhg
GRBS- 125mg/dl

ON SYSTEMIC EXAMINATION

CVS-
S1,S2 heard
No murmurs

Respiratory System
Patient examined in sitting position

Inspection:
Trachea central in position
Chest appears bilaterally symmetrical and elliptical in shape

Palpation
Trachea central in position
Measurements:
AP diameter:16cm
Transverse:26cm

Percussion:
                               Right   Left 
Supraclavicular.    R.   R
Infraclavicular.       R.   R
Mammary.               R.    R
Axillary.                   D.    D
Suprascapular.        R.   R
Infrascapular.          D.     D

Auscultation
                               Right Left 
Supraclavicular. NVBS.  NVBS
Infraclavicular. NVBS.    NVBS
Mammary.        NVBS   NVBS
Axillary. Decreased.   Decreased
Suprascapular. NVBS.   NVBS
Infrascapular.  Decreased Decreased



ABDOMEN:

 No tenderness,skin is smooth and shiny,no scars,sinuses



CNS- 
conscious,speech normal,no signs of meningeal irritation,sensory and motor system normal,gait- normal.

DIAGNOSIS- Chronic Renal Failure w/ pleural effusion


Investigations 



 










TREATMENT:-

. Injection lasix 40 mg iv BD
. TAB nodosis 50 mg po BD
. TAB shelcal 50 mg po BD
. TAB Nicardia 10 mg po BD
. Cap biod3 weekly once
. TAB DYTOR 20mg po.BD
. Vitals monitoring 6th hourly.

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