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. 

D Nikhil Venkata Reddy

Roll no 41

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.