78 YEAR OLD MALE , FARMER BY OCCUPATION CAME WITH SOB ON EXERTION, PEDAL EDEMA AND GENERALISED WEAKNESS SINCE 20 DAYS

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.



78 year old male with farmer by occupation, resident of Annaram came with chief complaints of SOB on exertion, pedal edema and generalised weakness since 20 days


HOPI-

Pt was apparently asymptomatic 3 months back, then developed SOB which gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations. 

Orthopnea (+)ve, PND (+)

Not h/o facial puffiness, no decreased urine output, no burning micturition

H/o fever on and off since 2 months


Past history-

Pt was diagnosed with dengue 1 month prior

K/c/o DM since 10 years, on T. Zoryl-m2 po/bd

K/C/O serizure disorder, on T. Carbamazepine 200mg po/od

Not k/c/o HTN, CAD, asthma, CVA, TB

No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena


Personal history-

Sleep adequate, appetite decreased, bowel movements irregular, bladder regular, occasional alcoholic, non smoker


General examination-

O/e- pt is conscious, coherent, cooperative with respect to place ,time and person

AFEBRILE

BP- 150/80mmgHg

PR- 81 BPM

RR-24cpm

SPO2- 99% 

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

JVP(-)



     











Systemic examination-

CVS- S1, S2 heard, no murmurs, 

apex in 6th ICS, MCL, no thrills

RS- BAE(+VE), NVBS

P/A- abdomen distended, umbilicus everted, no fluid thrill, soft, Bowel sounds(+)


INVESTIGATIONS-






Xray:
ECG:


2D ECHO:

USG:

Input and output:
Fever chart:
Review of USG:


Provisional diagnosis-

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

Treatment:

Fluid restriction < 1.5L/day

Salt restriction < 2.4g/day

TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)

TAB ZORY - M2 PO/BD

TAB ECOSPRIRIN - AV (70/20) PO/HS

TAB CARBAMAZEPINE 200mg PO/OD

BP-MONITORING 4th HRly

GRBS 6th HRly

                  8am-2pm-8pm

I/O CHARTING

TEMP CHARTING


SOAP Notes:


22/12/21  

78/M

S- no fever spikes, c/o SOB, not passed stools 


O-

BP- 120/70mmgHg

Pr- 81 BPM

Rr-24cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender

I/o- 500/900


A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi


P-

Fluid restriction <1.5l/day

Salt restriction <2.5gm/day

Inj LASIX 40mg iv/bd

T. Zoryl-m2 po/bd

T. Carbamazepine 200mg po/od

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting

Daily weight monitoring

T. Ecospirin-AV (75/20) po/od


23/12/21  

Ward

78/M


S- SOB decreased


O-

BP- 130/70mmgHg

Pr- 93 BPM

Rr-20cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender


A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi


P-

1. Fluid restriction <1.5l/day

2. Salt restriction <2.5gm/day

3. Inj LASIX 40mg iv/bd

4. Inj Nervigem 1amp in 100ml NS IV OD

5. Inj HAI

6. T. Carbamazepine 200mg po/od

7. T. Ecospirin-AV (75/20) po/od

8.Syp cremaffin 15 ml BD

9. Syp. Potchlor 10 ml in glass of water po/TID

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting



25/12/21

S- SOB decreased

O-
BP- 140/80mmgHg
Pr- 98 BPM
Rr-18cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting


Investigations-

Endoscopy-
No varices
No bleed in stomach
Few vascular ectasia in the antrum,no active bleed


26/12/21


S- SOB decreased

O-

BP- 130/90mmgHg

Pr- 95 BPM

Rr-20cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender


A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi


P-

1. Fluid restriction <1.5l/day

2. Salt restriction <2.5gm/day

3. Inj LASIX 40mg iv/bd

4. Inj Nervigem 1amp in 100ml NS IV OD

5. Inj HAI

6. T. Carbamazepine 200mg po/od

7. T. Ecospirin-AV (75/20) po/od

8.Syp cremaffin 15 ml BD

9. Syp. Potchlor 10 ml in glass of water po/TID

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting


28/12/21


S- SOB decreased


O-

BP- 120/70mmgH

Pr- 90 BP

Rr-18cp

SPO2- 99% @ra

 pallor (+)

Pedal edema (+), b/l, pitting typ

Clubbing (-)

CVS- S1, S2 heard

RS- BAE(+VE), NVB

P/A- soft, non tender


A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi


P-

1. Fluid restriction <1.5l/da

2. Salt restriction <2.5gm/da

3. Inj LASIX 40mg iv/b

4. Inj Nervigem 1amp in 100ml NS IV O

5. Inj HAI

6. T. Carbamazepine 200mg po/o

7. T. Ecospirin-AV (75/20) po/o

8.Syp cremaffin 15 ml B

9. Syp. Potchlor 10 ml in glass of water po/TI

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting

















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