1801006082 L

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Chief complaints:

75 years old male came to OPD with cc of pedal edema since 1month,shortness of breath since 20days,vomitings since 10days 

History of present illeness:

patient was apparently asymptomatic 1month back Than he developed bilateral pedal edema which is insidious in onset gradual in progression upto the knee and pitting type edema no aggrevating and no relieving factors .

Patient also complains of shortness of breath since 20days which is sudden in onset gradual in progression ,aggrevating on doing work, walking and temporarily relived on medication

and also he had history of vomitings which is sudden in onset,non billous type,non blood stained,4 episodes of vomitings per day (he vomit soon after taking food or juice)

And also he had productive cough

No history of fever,burning micturation,decreased frequency of urination,poor stream,chills and rigor

PAST HISTORY:

History of incidental finding of hypertension 20days back.

He had history of TB 18years ago for which he had taken medication for 6months and TB symptoms got subsided.

No history of diabetes, thyroid,epilepsy,asthma,

No history of any previous surgeries 

PERSONAL L HISTORY: 

Diet:mixed

Sleep:adequate but decresed since 10days 

Appetite:normal but decreased since 10days 

Bladder and bowel movement: regular

Addictions:he started taking alcohol since 30years of age,daily 1quarter daily and his last alcohol uptake was 1 month back.

Dialy Routine:

75years old male previously he worked as farmer but now he stay in his home patient wake up at 4:30am morning and do his regular activities and he had breakfast with rice and vegetables curry at 7:30am and he stays in home at 1pm he had lunch(rice+vegetables curry)and had nap of sleep for about 30min and wake up and at 7pm had there dinner(some times chepati,rice,curry) and at 9oclock he sleeps

FAMILY HISTORY:

No significant family history  

TREATMENT HISTORY:

No significant treatment history 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative .

Pallor:present

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 

Pedal edema: bilateral pedal edema ,pitting type

VITALS:(03/01/2022)

TEMPERATURE: Afebrile

PR:82bpm

RR:21cpm

BP:130/80 mmhg

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No signs of volume loss

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspectory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

MEASUREMENTS-

chest circumfere

Transverse diameter is:26cm

Anteroposterior diameter is :16cm

Chest expansion-

Tactile vocal phremitus- present in all areas 

And reduced in right and left infra axillary and right and left subscapular 

Percussion:-

                                       Right    left

Supraclavicular- Resonant (R) (R) 

Infraclavicular-                     (R) (R) 

Mammary-                               R R

Axillary-                                  (R) (R) 

Infra axillary-                        dull dull

Suprascapular-                      (R) (R) 

Interscapular-                        (R) (R) 

Infrascapular-                      dull dull

Auscultation:-

                                      Right Left

Supraclavicular- Normal vesicular Breath sounds (NVBS)

Infraclavicular- (NVBS) (NVBS)

Mammary-        (NVBS) (NVBS)

Axillary-             (NVBS) (NVBS)

Infra axillary-decreased decreased

                                                         

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- decreased decreased

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP -  mild raised

Palpation :

 Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs

Per abdomen: 

On inspection:

Shape - flat

Abdomen moves equally with respiration. 

Umbilicus inverted

No scars and sinuses present. 

No visible pulsatios , no engorged veins

On palpation: 

No tenderness 

No rebound tenderness, no gaurding, no rigidity

No organonegaly

On percussion: 

No fluid thrill 

No shifting dullness

On Auscultation:

Bowel sounds heard

CNS EXAMINATION:

no focal neurological deficit 

INVESTIGATIONS::

CBP:

Hemogram 

HB                  7.4g /dl normal 13-17 

Lymphocytes 15.       Normal 20-40 

MCHC.            30.5    Normal 31.5 to 34.5

Rbc                 2.4 million 

USG::

1.bilateral pleural Effusion   l>r

2.Grade 3 RPDin rt kidney

3.Grade 2 RPD left kidney

2D Echo: Aortic valve - sclerotic and thickened 

X RAY:

ECG:.                                                             

ABG

PH.      7.39 

PCo2.  27mmhg 

Po2      89.9mmhg 

CUE: Complete urine examination

 albumin +1

Serum electrolytes 

Sodium               138 mEq/l

Potassium           3.7 mEq/l

Chloride.              104 mEq/l

Calcium ionised  0.92 mmol/l

Provisional daigonosis:

Acute on chronic CKD

Heart failure with reduced ejection fraction

B/L pleural effusion

Anaemia 

Treatment history:

1) inj LASIX 20mg IV BD

3)CAP BIOD3 PER ORALLY OD

4)TAB OROFER XT PER ORALLY OD

5)TAB SHELCAL PER ORALLY OD

6)INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE