70 Y/M WITH SOB, SWELLING OF BOTH LOWER LIMBS

 


This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


PATIENT WAS BROUGHT TO CASUALITY WITH COMPLAINTS OF BREATHLESSNESS SINCE 4 DAYS

C/O SWELLING OF BOTH LOWER LIMBS SINCE 4 DAYS.

HOPI: PT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK THEN HE DEVELOPED BREATHLESSNESS GRADE III NYHA , INSIDIOUS ONSET ,GRADUALLY PROGRESSIVE, AGGREVATED WITH WALKING AND RELEIVING WIT REST.

H/O ORTHOPNEA PRESENT.

C/O PEDAL EDEMA SINCE 4 DAYS , INSIDIOUS ONSET , PITTING TYPE

NO H/O PND, CHEST PAIN, PALPITATION, NO H/O FEVER, COLD, COUGH.

NO H/O BURNING MICTURITION, DECREASED URINE OUTPUT.

PAST H/O :

K/C/O PULMONARY TB 1 YEAR BACK AND USED ATT.

NOT AA K/C/O HTN, DM, CVA, CAD, ASTHMA, THYROID DISORDERS.

GENERAL EXAMNATION :

PATIENT IS C/C/C

TEMP-AFEBRILE

PR-58BPM

RR-22CPM

BP-120/70 MMHG

SPO2- 98 % AT RA

GRBS- 102 MG/DL

SYSTEMIC EXAMINATION

CVS - S1,S2 HEARD

RS - BAE PRESENT, COARSE CREPTS IN LEFT ICA,MA, AA,ISA

CNS - NFND

P/A - SOFT, NON TENDER, BOWEL SOUNDS HEARD

INVESTIGATIONS:

HBsAg-RAPID 17-01-2024 02:29:PM Negative

Anti HCV Antibodies - RAPID 17-01-2024 02:29:PM Non Reactive

 

HEMOGRAM:

HB- 9.1 GM/DL

TLC: 7,100 CELLS/CC

PLATELETS: 1.76 LAKHS/CC


COMPLETE URINE EXAMINATION (CUE) 17-01-2024 02:29:PM


COLOUR Pale yellow


APPEARANCE Clear


REACTION Acidic


SP.GRAVITY 1.010


ALBUMIN +


SUGAR Nil


BILE SALTS Nil


BILE PIGMENTS Nil


PUS CELLS 2-3


EPITHELIAL CELLS 3-4


RED BLOOD CELLS Nil


CRYSTALS Nil


CASTS Nil


AMORPHOUS DEPOSITS Absent


OTHERS Nil

 

RFT 17-01-2024 02:29:PM


UREA 59 mg/dl 50-17 mg/dl


CREATININE 2.1 mg/dl 1.3-0.8 mg/dl


URIC ACID 8.6 mg/dl 7.2-3.5 mg/dl


CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 2.5 mg/dl 4.5-2.5 mg/dl


SODIUM 140 mEq/L 145-136 mEq/L


POTASSIUM 4.3 mEq/L 5.1-3.5 mEq/L


CHLORIDE 106 mEq/L 98-107 mEq/L


LIVER FUNCTION TEST (LFT) 17-01-2024 02:29:PM


Total Bilurubin 0.88 mg/dl 1-0 mg/dl


Direct Bilurubin 0.22 mg/dl 0.2-0.0 mg/dl


SGOT(AST) 10 IU/L 35-0 IU/L


SGPT(ALT) 18 IU/L 45-0 IU/L


ALKALINE PHOSPHATE 237 IU/L 119-56 IU/L


TOTAL PROTEINS 5.3 gm/dl 8.3-6.4 gm/dl


ALBUMIN 3.7 gm/dl 4.6-3.2 gm/dl


A/G RATIO 2.31

 

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-01-2024 11:49:PM

 


SODIUM 139 mEq/L 145-136 mEq/L


POTASSIUM 3.5 mEq/L 5.1-3.5 mEq/L


CHLORIDE 99 mEq/L 98-107 mEq/L


CALCIUM IONIZED 1.21 mmol/L mmol/L


BLOOD UREA 18-01-2024 11:49:PM 53 mg/dl 50-17 mg/dl

 

SERUM CREATININE 18-01-2024 11:49:PM 1.2 mg/dl 1.3-0.8 mg/dl


POST LUNCH BLOOD SUGAR 18-01-2024 11:49:PM 124 mg/dl 140-0 mg/dl

 

RFT 19-01-2024 11:55:PM


UREA 53 mg/dl 50-17 mg/dl


CREATININE 2.2 mg/dl 1.3-0.8 mg/dl


URIC ACID 8.2 mg/dl 7.2-3.5 mg/dl


CALCIUM 8.4 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 2.8 mg/dl 4.5-2.5 mg/dl


SODIUM 139 mEq/L 145-136 mEq/L


POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L


CHLORIDE 104 mEq/L 98-107 mEq/L

 

RFT 22-01-2024 11:55:PM


UREA 46 mg/dl 50-17 mg/dl


CREATININE 2.2 mg/dl 1.3-0.8 mg/dl


URIC ACID 8.2 mg/dl 7.2-3.5 mg/dl


CALCIUM 9.0 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 2.8 mg/dl 4.5-2.5 mg/dl


SODIUM 141 mEq/L 145-136 mEq/L


POTASSIUM 3.3 mEq/L 5.1-3.5 mEq/L


CHLORIDE 104 mEq/L 98-107 mEq/L

 

USG  DONE ON 18/1/24

B/L GRADE III RPD CHANGES

B/L MILD PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE

2D ECHO:

EF -40%

RA, RV , LA, LV DILATED

RWMA +, LAD HYPOKINETIC, MILD LVH, RCA, LCX HYPOKINESIA

IVC DILATED AND INTACT

MODERATE MR+, MODERATE TR WITH PAH

MODERATE AR, ECCENTRIC TR

MODERATE  LV DYSFUNCTION

NO AS/MS. DIASTOLIC DYSFUNCTION +, NO PE.

TREATMENT:

FLUID  RESTRICTION <1.5 L/DAY

SALT RESTRICTION <2 GM/DAY

TAB. ISOLAZINE 20/37.5  1/2 TAB PO TID 1/2--1/2--1/2

TAB. LASIX 40 MG PO BD 1--0--1

TAB. ALDACTONE 25MG PO OD 0--1--0

TAB. ULTRACET PO BD 1--0--1

TAB. PAN 40 MG PO OD 1--0--0

TAB. SHELCAL -CT PO OD 0--1--0

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