Short case 1801006051

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.