1801006022- Short case
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-centred online learning portfolio and your valuable comments on comment box is welcome.
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,
Clinical images
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
Chest X Ray
Obliteration of costophrenic angle
Haemoglobin-9.8g/dl
Neutrophils-95%
Total count-12,800 cells/ cumm
Lymphocytes-2%
Eosinophils-0%
PCV-28.7 vol%
Urea-73 mg/dl
Creatine-4.3 mg/dl
Calcium-7.5mg/dl
Sodium-131mg/dl
Total bilitubin-1.34 mg/dl
Direct bilirubin-0.3 mg/dl
AST-358 IU/L
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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