78 YEAR OLD MALE , FARMER BY OCCUPATION CAME WITH SOB ON EXERTION, PEDAL EDEMA AND GENERALISED WEAKNESS SINCE 20 DAYS

 

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 

 

78 year old male with farmer by occupation, resident of Annaram came with chief complaints of SOB on exertion, pedal edema and generalised weakness since 20 days

 

HOPI-

Pt was apparently asymptomatic 3 months back, then developed SOB which gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations. 

Orthopnea (+)ve, PND (+)

Not h/o facial puffiness, no decreased urine output, no burning micturition

H/o fever on and off since 2 months

 

Past history-

Pt was diagnosed with dengue 1 month prior

K/c/o DM since 10 years, on T. Zoryl-m2 po/bd

K/C/O serizure disorder, on T. Carbamazepine 200mg po/od

Not k/c/o HTN, CAD, asthma, CVA, TB

No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena

 

Personal history-

Sleep adequate, appetite decreased, bowel movements irregular, bladder regular, occasional alcoholic, non smoker

 

General examination-

O/e- pt is conscious, coherent, cooperative with respect to place ,time and person

AFEBRILE

BP- 150/80mmgHg

PR- 81 BPM

RR-24cpm

SPO2- 99% 

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

JVP(-)

 

Systemic examination-

CVS- S1, S2 heard, no murmurs,  

apex in 6th ICS, MCL, no thrills

RS- BAE(+VE), NVBS

P/A- abdomen distended, umbilicus everted, no fluid thrill, soft, Bowel sounds(+)

INVESTIGATIONS-

 

 

Provisional diagnosis-

 

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

 

Treatment:

 

Fluid restriction < 1.5L/day

Salt restriction < 2.4g/day

TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)

TAB ZORY - M2 PO/BD

TAB ECOSPRIRIN - AV (70/20) PO/HS

TAB CARBAMAZEPINE 200mg PO/OD

BP-MONITORING 4th HRly

GRBS 6th HRly

                  8am-2pm-8pm

I/O CHARTING

TEMP CHARTING

 

SOAP Notes:

 

22/12/21  

78/M

S- no fever spikes, c/o SOB, not passed stools 

 

O-

BP- 120/70mmgHg

Pr- 81 BPM

Rr-24cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender

I/o- 500/900

 

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

 

P-

Fluid restriction <1.5l/day

Salt restriction <2.5gm/day

Inj LASIX 40mg iv/bd

T. Zoryl-m2 po/bd

T. Carbamazepine 200mg po/od

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting

Daily weight monitoring

T. Ecospirin-AV (75/20) po/od

 

23/12/21  

Ward

78/M

 

S- SOB decreased

 

O-

BP- 130/70mmgHg

Pr- 93 BPM

Rr-20cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender

 

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

 

P-

1. Fluid restriction <1.5l/day

2. Salt restriction <2.5gm/day

3. Inj LASIX 40mg iv/bd

4. Inj Nervigem 1amp in 100ml NS IV OD

5. Inj HAI

6. T. Carbamazepine 200mg po/od

7. T. Ecospirin-AV (75/20) po/od

8.Syp cremaffin 15 ml BD

9. Syp. Potchlor 10 ml in glass of water po/TID

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting

 

25/12/22

S- SOB decreased

O-

BP- 140/80mmgHg

Pr- 98 BPM

Rr-18cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender 

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi

P-

1. Fluid restriction <1.5l/day

2. Salt restriction <2.5gm/day

3. Inj LASIX 40mg iv/bd

4. Inj Nervigem 1amp in 100ml NS IV OD

5. Inj HAI

6. T. Carbamazepine 200mg po/od

7. T. Ecospirin-AV (75/20) po/od

8.Syp cremaffin 15 ml BD

9. Syp. Potchlor 10 ml in glass of water po/TID

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting

Investigations-

Endoscopy-

No varices

No bleed in stomach

Few vascular ectasia in the antrum,no active bleed

26/12/22

S- SOB decreased

O-

BP- 130/90mmgHg

Pr- 95 BPM

Rr-20cpm

SPO2- 99% @ra

Severe pallor (++)

Pedal edema (+), b/l, pitting type

Clubbing (-)

CVS- S1, S2 heard,

RS- BAE(+VE), NVBS

P/A- soft, non tender

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi 

P-

1. Fluid restriction <1.5l/day

2. Salt restriction <2.5gm/day

3. Inj LASIX 40mg iv/bd

4. Inj Nervigem 1amp in 100ml NS IV OD

5. Inj HAI

6. T. Carbamazepine 200mg po/od

7. T. Ecospirin-AV (75/20) po/od

8.Syp cremaffin 15 ml BD

9. Syp. Potchlor 10 ml in glass of water po/TID

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting 

28/12/22 

S- SOB decreased

O-

BP- 120/70mmgH

Pr- 90 BP

Rr-18cp

SPO2- 99% @ra

 pallor (+)

Pedal edema (+), b/l, pitting typ

Clubbing (-)

CVS- S1, S2 heard

RS- BAE(+VE), NVB

P/A- soft, non tender

A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi 

P-

1. Fluid restriction <1.5l/da

2. Salt restriction <2.5gm/da

3. Inj LASIX 40mg iv/b

4. Inj Nervigem 1amp in 100ml NS IV O

5. Inj HAI

6. T. Carbamazepine 200mg po/o

7. T. Ecospirin-AV (75/20) po/o

8.Syp cremaffin 15 ml B

9. Syp. Potchlor 10 ml in glass of water po/TI

Monitor vitals 4th hrly

GRBS- 6th hrly

I/o charting