55 YR OLD MALE WITH SOB AND SWELLINGS OF BOTH LOWER LIMBS

202413871 islavath hanma
CHIEF COMPLAINTS:
SWELLING OF BOTH LOWER LIMBS SINCE 3 MONTHS.
DIFFICULTY IN BREATHING SINCE ONE MONTH.
HISTORY OF PRESENT ILLNESS:
-PATIENT WAS APPARENTLY NORMAL 3-4 MONTHS BACK.
-HE THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS-PITTING TYPE EXTENDING UPTO
THE KNEE-NOT RELIEVED ON LYING DOWN ASSOCIATED WITH PAIN AND TENDERNESS.
-HE VISITED A HOSPITAL AND WAS TOLD TO HAVE CKD AND PUT ON MEDICAL
MANAGEMENT.USED MEDICATION FOR 1 MONTH AND STOPPED.
-C/O DIIFICULTY IN BREATHING SINCE ONE MONTH-INITIALLY GRADE 2(MMRC) NOW
PROGRESSED TO GRADE 3-RELIEVED ON TAKING REST.
-C/O DECREASED URINARY OUTPUT SINCE 1 WEEK.
-C/O DECREASED APPETITE,CONSTIPATION.
NO C/O FEVER,NAUSEA,VOMITINGS,CHEST PAIN,PND.
-C/O CAD-CABG DONE 8 YEARS BACK.
-K/C/O DM TYPE 2 SINCE 5 YEARS.
-K/C/O HTN SINCE 1 YEAR USING MEDICATION.
-NOT A K/C/O TB,EPILEPSY,CVA,BRONCHIAL ASTHMA,THYROID DISORDERS.
TREATMENT HISTORY:
NO SIGNIFICANT HISTORY.
PERSONAL HISTORY:
MARRIED
OCCUPATION-HOTEL WORKER
APPETITE- LOST
DIET- MIXED
BOWELS- CONSTIPATION
MICTURITION- ABNORMAL:DECREASED SINCE 5 DAYS
KNOWN ALLERGIES- NO
HABITS-
a)ALCOHOL: STOPPED 2 MONTHS BACK.
b)TOBACCO- SMOKING: STOPPED 2 MONTHS BACK.
GENERAL EXAMINATION:
PT IS CONCIOUS, COHERENT, COOPERATIVE
PEDAL EDEMA+++
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPADENOPATHY
TEMP- AFEBRILE
PR- 108 BPM
RR- 24CPM
BP- 140/70MMHG
GRBS: 147 MG%
CVS- S1 S2 HEARD
RS- DECREASED BS IN RIGHT SIDE MAMMARY AREA,IAA,ISA.
CNS- NAD
P/A- SOFT, NON TENDER BOWEL SOUNDS +
CNS : NFND
INVESTIGATION
CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCV
NameValueNameValueLIVER FUNCTION TEST (LFT) 26-03-2024 04:07:PM Total Bilurubin0.64
mg/dlDirect Bilurubin0.19 mg/dlSGOT(AST)13 IU/LSGPT(ALT)17 IU/LALKALINE
PHOSPHATASE198 IU/LTOTAL PROTEINS5.2 gm/dlALBUMIN2.84 gm/dlA/G RATIO1.20RFT 26-
03-2024 04:07:PM UREA91 mg/dlCREATININE3.4 mg/dlURIC ACID10.1 mmol/LCALCIUM10.0
mg/dlPHOSPHOROUS3.5 mg/dlSODIUM142 mmol/LPOTASSIUM5.0 mmol/L.CHLORIDE105
mmol/LAnti HCV Antibodies - RAPID26-03-2024 04:07:PMNon Reactive HBsAg-RAPID26-03-2024
04:07:PMNegative COMPLETE URINE EXAMINATION (CUE) 26-03-2024 04:07:PM COLOURPale
yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGAR+BILE
SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-4RED BLOOD
CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil
ULTRASOUND (26/03/2024):
FINDINGS:
-E/O MODERATE FREE FLUID NOTED IN THE RIGHT AND LEFT PLEURAL SPACES.
-EDEMATOUS CHANGES NOTED IN THE ANTERIOR ABDOMINAL WALL.
IMPRESSION:
-BILATERAL PLEURAL EFFUSION.
-ANTERIOR ABDOMINAL WALL EDEMA.
-MILD ASCITES.
-BILATERAL GRADE 1 RPD CHANGES.
2-D ECHO (27/03/2024):
-MILD MR+ / MILD AR+ / TR+ WITH PAH. EF 20%
-DILATED CARDIAC CHAMBERS.
-GLOBAL HYPOKINESIA OF LV.
-SEVERE LV SYSTOLIC DYSFUNCTION.
-GRADE 2 DIASTOLIC DYSFUNCTION.
-MILD PERICARDIAL EFFUSION.
DIAGNOSIS
CHRONIC KIDNEY DISEASE-STAGE 4
WITH TYPE 2 DM
WITH CAD
WITH HFrEF (EF-20%)
S/P: CABG 8 YEARS BACK
TREATMENT GIVEN
1. FLUID RESTRICTION LESS THAN 1 LITRE/DAY
2. SALT RESTRICTION LESS THAN 2-3 GM/DAY
3. TAB.NODOSIS 500 MG PO/OD
4. TAB.SHELCAL-CT PO/OD
5. INJ.HUMAN ACTRAPID INSULIN SC/TID (BEFORE MEALS ACCORDING TO GRBS)
6. TAB.AUGMENTIN 625 MG PO/BD
7. TAB.PAN 40 MG PO/OD
8. GRBS 7TH HOURLY PROFILE.
9. TAB.MET-XL 25 MG PO/OD
10. TAB.DAPAGLIFOZIN 10 MG PO/OD
11. TAB.DYTOR 100 MG PO/BD
ADVICE AT DISCHARGE
1. FLUID RESTRICTION LESSTHAN 1 LITRE/DAY
2. SALT RESTRICTION LESS THAN 2-3 GM/DAY
3. TAB.NODOSIS 500 MG PO/OD
4. TAB.SHELCAL-CT PO/OD
5. INJ.HUMAN ACTRAPID INSULIN SC/TID 6U 6U 6U
6. TAB.AUGMENTIN 625 MG PO/BD FOR 4 DAYS
7. TAB.PAN 40 MG PO/OD
8. TAB.MET-XL 25 MG PO/OD
9. TAB.DAPAGLIFOZIN 10 MG PO/OD
10. TAB.DYTOR 100 MG PO/BD






Comments

Post a Comment

Popular posts from this blog

59 K. Rithika Vasantha

Image
Hi all. This is Rithika, a third semester medical student.              This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.  Note :This is an ongoing case and will be updated as and when the information is provided. This e-log has been made under the guidance of Dr. Siddharth.  A 70 YEAR OLD MALE WITH SOB AND SWELLING, DISCHARGE FROM RT. LOWER LIMB( CELLULITIS)  Chief complaint : • Altered sensorium , since 2 days • SOB grade IV , since 5 days • Pedal edema grade III, since 7 days • Rt. Lower limb cellulitis, since 7 days History of presenting illness: • A 70 yr old male, farmer by occupation, was apparently asymptomatic 2 yrs...
Read more

59 K. Rithika Vasantha

June 2021-BIMONTHLY BLENDED ASSESSMENT                   Greetings to one and all who are currently reading my blog.            This is Rithika, roll no 59 , a third semester medical student. And this blog us currently an assignment given to me.        Question link: assignment link    👉My first question  was to go through answers in the following link and share my peer review on what's good and bad about it.   Link: question link    ❄ Answer:  I have decided to take, refer and study pulmonology case from 10 different links and this is my peer review about it🙂         Out of the 10 different case sheets I have referred, the details of the patient are: Patient details: details Evolution of symptomology : 20 yrs back-First episode of shortness of breath(lasted for 1 week during January)and continued in the same pattern for 7 years ↓ 12 yea...
Read more

GM final yr elog 1

Image
Greetings to one and all who are currently reading my blog. This is Rithika, 8th semester medical student.                                               This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.  Note : This is an on-going case and will be updated as and when I receive any information.  A 45 YEAR OLD FEMALE WITH WEAKNESS IN BOTH UPPER AND BOTH LOWER LIMBS PRESENTING COMPLAINT    Excessive weakness and fatigue in both her legs and also her upper limbs since 4 days.  ASSOCIATED COMPLAINT  Loss of appetite and feeling of ...
Read more