70Yr old male with bilateral pedal oedema and Shortness of breath

 


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. 

CHIEF COMPLAINTS: 

The patient presented to the medical OP with 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 ago and then he developed bilateral pedal oedema which was gradually progressive and of pitting type up to knee joint.
He then developed Shortness of breath about 12 days ago which progressed gradually from grade 2 to grade 4.
*No history of fever
*No history of burning micturition
*No history of diarrhoea

HISTORY OF PAST ILLNESS:

Known case of hypertension since 10 years
 N/k/c/o:DM,ASTHAMA,CAD,EPILEPSY, HYPOTHYROIDISM. 

TREATMENT HISTORY:
NSAID abuse

PERSONAL HISTORY:

*Diet: mixed
*Appetite : Reduced
*Micturition: normal
*Bowel and bladder movements: regular
*Addictions: occasional consumption of Alcohol 










ON EXAMINATION

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

*Pallor - present

*Icterus- absent

*Cyanosis- absent

*Clubbing- absent

*Koilonychia - absent

*Lymphadenopathy - absent

*Edema - Bilateral pedal odema 

 VITALS 

* Temperature- Afebrile
* Pulse rate- 82 BPM
* Respiratory rate- 16 CPM
* Bp-  142/80 mmhg
* GRBS- 125mg/dl

ON SYSTEMIC EXAMINATION

CVS
 S1,S2 heard
No murmurs heard

Respiratory System
Patient examined in sitting position

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

Palpation:
Trachea is 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, the skin is smooth and shiny, no scars or sinuses


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


Investigations








 DIAGNOSIS

 Chronic Renal Failure w/ pleural effusion


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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