1801006020 - short case
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 .
Shortness of breath 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 .
No history of fever , chills and rigor , burning micturition , decreased frequency of urination and poor stream .
No history of dark colour urine .
PAST HISTORY
Patient was asymptomatic 20 days back then he developed shortness of breath and pedal edema for which he went to local hospital and they given medication but symptoms not releaved , then they went to a hospital in miryalaguda they referred to our hospital.
Diagnosed as hypertensive 1 month back ( insidental finding )
18 yrs back he developed tb for which he had take antitubercular for 6 months and tb symptoms subsided.
Not a known case of diabetes , asthma , epilepsy, thyroid.
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 and at 1pm he had lunch(rice+vegetables curry)and at 7pm had there dinner(some times chepati,rice,curry) and he sleeps at 9 pm .
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 30 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
No signs of volume loss
No dilated veins,sinuses, visible pulsations.
Palpation:-
No local rise of temperature and tenderness.
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 - not raised .
Palpation :
Apex beat can be palpable in 5th inter costal space
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:
Impression- grade 3 Rpd of right kidney
Grade 2 Rpd of left kidney
Bilateral pleural effusion - left is more than right side
2) HEAMOGRAM:
Hb - 7.4 gm/ dl
Lymphocytes- 15 %
Pcv - 24.3 vol%
Mchc -30.5 %
RBC - 2.41 million/cumm .
Platelet count - 90,000
Smear -
normocytic hypochromic with anisopokilocytosis
Macrocytes , macro ovalocytes seen
Platelets count reduced on smear .
Impression - dimorhic anemia with thrombocytopenia.
3) COMPLETE URINE EXAMINATION:
COLOR : pale yellow
Appearance - clear
Specific gravity- 1.018
Albumin +
Pus cells 2-4
Epithelial cells 2-3
4) Serum electrolytes
Sodium - 138
Potassium- 3.8
Chloride - 104
Ionized calcium - 0.92
5)SERUM CREATININE: 6.6 mg/dl ( normal 0.7 to 1.1 )
6)BLOOD UREA: 181 mg/dl
Provisional diagnosis
Acute on Ckd, Pleural effusion? IDA?
Treatment
inj LASIK20mg IV BD
CAP BIOD3 PER ORALLY OD
TAB OROFER XT PER ORALLY OD
Tab SHELCAL PER ORALLY OD
INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE
14-03-2023
Follow Up
I contacted him through phone call , he said
He is undergoing regular hemodialysis.
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