75 yrs old man with sob , bilateral pedal oedema and vomiting. .

 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 PUR 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

75 yrs old male came to the OPD with CC:vomiting since 10 days ,Sob since 20 days Bilateral pedal oedema since 30 days . 

HOPI: 

Patient was apparently asymptomatic 30 days back then he developed 

Bilateral pedal oedema which is insidious in  onset,  gradually progressive  , pitting type , extending from knee to foot , no agrrevating and relieving factors . 

Sob which is insidious in onset gradually progressive, grade 4 , agrrevates on walking

Vomiting - 4- 5 / day  , non bilious , non blood stained , immediately after taking water and food .

PAST HISTORY 

18 yrs back he developed tb for which he had take antitubercular for 6 months and tb symptoms subsided. 

Diagnosed as hypertensive 1 month back ( insidental finding ) 

Not a known case of diabetes , asthma , epilepsy, thyroid. 

No history of fever , chills and rigor , burning micturition , decreased frequency of urination . 

No history of previous surgery 

PERSONEL HISTORY: 

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 at 7pm had there dinner(some times chepati,rice,curry) and at 9oclock he sleep

Diet - mixed 

Appetite - decreased since 10 days 

Sleep - decreased since 10 days 

Bowel and bladder - regular 

Addictions - consumes alcohol from 30 years of age , 1 quarter daily , stopped 3 months back. 

FAMILY HISTORY: no relavent family history.

Treatment history : no treatment history. 

GENERAL EXPLANATION:

pt is conscious, coherent, cooperative and we'll oriented with time,place,person

Pallor: present 

ICTERUS: absent 

Cyanosis: absent 

Clubbing: absent 

Lymphadenopathy: absent 

Pedal edema: bilateral pedal oedema, pitting type.

VITALS:

TEMP: 97.2 F

PR: 80/min

RR: 22/min 

BP: 130/80 mmHg 

SYSTEMIC EXAMINATION:

Respiratory system

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 5 th Intercoastal space

No signs of volume loss

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

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

MEASUREMENTS-

chest circumference 

- transverse 28 cm 

- AP - 16 cm 

Tactile vocal phremitus- present in all areas but reduced in  right and left infra axillary and right and left subscapular regions 

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 sound s       (NVBS) 

Infraclavicular-          (NVBS)                 (NVBS)

Mammary-                 (NVBS)                 (NVBS)

Axillary-                      (NVBS)                 (NVBS)

Infra axillarry          decreased        decreased 

                                                          

Suprascapular-          (NVBS)                (NVBS)

Interscapular-            (NVBS)                (NVBS)

Infrascapular-       decreased      decreased 

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP -   raised

Palpation :

 Apex beat can be palpable in 5th inter costal space

No thrills and parasternal heaves can be felt

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:NO focal neurological deficit

INVESTIGATION:

X ray

1)USG:

2 ) colour Doppler 2 d echo 

3) HEAMOGRAM: 

Hb - 7.4 gm/ dl 

Lymphocytes- 15 % 

RBC - 2.41 million/cumm . 

4) COMPLETE URINE EXAMINATION: 

 5) Serum electrolytes 

6)SERUM CREATININE:

7)BLOOD UREA:

8) ABG

9) ECG 

10) blood grouping 

Provisional diagnosis

Acute on Ckd,  Pleural effusion? Heart failure? IDA? 

Treatment

 inj LASIK20mg IV BD

CAP BIOD3 PER ORALLY OD

Ecosprin 

TAB OROFER XT PER ORALLY OD

Tab  SHELCAL PER ORALLY OD

INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE