SHORT CASE(General Medicine Blog-14)

17th January, 2023.

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.

A 70 years old male patient came to our hospital with cheif complaints of-
Bilateral pedal edema since 1 month
Decreased urine output since 25 days
Shortness of Breath since 25 days.

Date of admission-24/12/2022

History of present illness:-
Patient was apparently asymptomatic 10 days back than he noticed pitting type of bilateral pedal edema since 10 days
Decreased urine output since 3 days 
Associated with SOB (Grade 2).
Associated with loss of appetite, nausea and loose stools 
No history of fever
No history of burning micturition.

History of past illness:-
Not a known case of hypertension, diabetes, asthma, tb, epilepsy.

Personal history:-
Patient has normal eating habit with mixed diet
Appetite-Decreased
Sleep-Inadequate
Bowel and bladder movements-Regular
Micturition-Normal
Occasionally alcohollic
Tobacco chewing since 40 years.

Daily routine-
Patient used to wake up at 6.00AM in the morning and does his daily work and takes breakfast at 9.00AM, takes lunch at 2.00PM, and dinner at 8.00PM, and goes to bed by 10.00PM.

Drug and allergic history:-
No known relevant drug and allergic history.

Family history:-
No significant family history.

General examination:-
Patient is conscious and coherent and non-cooperative
No Pallor
No Icterus
No Clubbing
No Dehydration
No Malnutrition 
Bilateral pedal edema

Vitals-
Temparature-Afebrile
RR-30cpm
Pulse rate-102bpm
BP-120/80 mm/hg

SYSTEMIC EXAMINATION-

CARDIOVASCULAR SYSTEM-
Inspection-
Chest wall-Symmetrical
Shape-Pectus excavatum
No precardial bulge
No dilated veins
No scars 
No sinuses
Palpation-
Apical impulse-Present 2cms lateral to the midclavicular line
No dilated veins
Percussion-
Dullness heard at 5th Intercostal area
Ascultation-
S1 S2 heard

RESPIRATORY SYSTEM-
Inspection-
Chest-Symmetrical
Shape-Pectus excavatum
Trachea-Midline
No drooping of shoulders
Supra clavicular and infra clavicular hollowing is seen
No sinuses
No scars
No dilated veins
Abdomino-thorasic movement with respiration.
Palpation-
Chest-Symmetrical chest movements i.e., Symmetric expansion
Trachea-Midline
Percussion-
Non-tender
Dullness on percussion
Ascultation-
Breath sounds-Vesicular
Added sounds-Crackles

ABDOMEN:-
Shape of the abdomen-Scaphoid
No tenderness
No palpable mass
Hernial orifice-Normal
No free fluid
No bruits
Liver- Not palpable
Spleen-Not palpable

CENTRAL NERVOUS SYSTEM:-
No abnormality detected

Provisional diagnosis:-
Pleural effusion


Investigations:-
Hemogram
Serum electrolytes
Serum creatinine
Random blood sugar
Blood urea
CUE
LFT
USG
Colour Doppler 2D Echo
Chest X-Ray
ECG


Final diagnosis:-
CKD

Treatment:-
Inj. Lasix 40mg IV/BD
Inj. Piptaz 2.25g IV/TID
Tab. Nodosis 500mg PO/BD
Tab. Orofer PO/OD
Salt and fluid restriction

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