A 65 YR OLD M ALE CAME WITH C/O PEDAL EDEMA AND ABDOMINAL DISTENSION SINCE 6 DAYS

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.

 C/O PEDAL EDEMA SINCE 6 DAYS

C/O ABDOMINAL DISTENSION SINCE 6 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 DAYS THEN DEVELOPED PEDAL EDEMA INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE FROM ANKLE TO HIP JOINT PITTING TYPE 

C/O ABDOMEN DISTENSION INSIDIOUS IN ONSET

H/O COUGH, NON PRODUCTIVE

H/O ORTHOPNEA, HEADACHE, DECREASED URINE OUTPUT

H/O CONSTIPATION AND BLOTING

H/O BURNING TYPE OF PAIN IN EPIGASTRIUM 

NO H/O PND, CHEST PAIN, PALPITATIONS

NO H/O PAIN ABDOMEN , BURNING MICTURITION

PAST HISTORY:

K/C/O HYPERTENSION SINCE 6 MONTHS AND NOT ON REGULAR MEDICATION , NOW USING TAB SACUV 200 MG

DM SINCE 4YEARS AND ON TAB GLIMI M2

H/O TB 2 YRS BACK AND COMPLETED ATT COURSE

N/K/C/O ASTHMA, EPILEPSY, CVA, CAD

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER: DECREASED URINE OUTPUT

ADDICTIONS: ALCOHOL QUATER SINCE 20 YRS

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:140/80 MM HG

PR:80 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

INVESTIGATION:

COMPLETE URINE EXAMINATION (CUE) 24-01-2024 05:26:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +++

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 4-5

EPITHELIAL CELLS 2-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

 

HBsAg-RAPID 24-01-2024 05:26:PM Negative

Anti HCV Antibodies - RAPID 24-01-2024 05:26:PM Non Reactive

 

RFT 24-01-2024 05:28:PM

UREA 19 mg/dl 42-12 mg/dl

CREATININE 1.2 mg/dl 1.3-0.9 mg/dl

URIC ACID 5.8 mg/dl 7.2-3.5 mg/dl

CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.2 mg/dl 4.5-2.5 mg/dl

SODIUM 135 mEq/L 145-136 mEq/L

POTASSIUM 4.4 mEq/L 5.1-3.5 mEq/L

CHLORIDE 99 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 24-01-2024 05:28:PM

Total Bilurubin 1.00 mg/dl 1-0 mg/dl

Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 41 IU/L 35-0 IU/L

SGPT(ALT) 28 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 283 IU/L 128-53 IU/L

TOTAL PROTEINS 5.6 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.68 gm/dl 5.2-3.5 gm/dl

A/G RATIO 0.92

POST LUNCH BLOOD SUGAR 24-01-2024 05:29:PM 276 mg/dl 140-0 mg/dl

 

HEMOGRAM ON 24/1/24

HAEMOGLOBIN # 8.6 gm/dl 13.0 - 17.0 Colorimetric

TOTAL COUNT 4,900 cells/cumm 4000 - 10000 Impedence

NEUTROPHILS 67 % 40 - 80 Light Microscopy

LYMPHOCYTES 22 % 20 - 40 Light Microscopy

EOSINOPHILS 02 % 01 - 06 Light Microscopy

MONOCYTES 09 % 02 - 10 Light Microscopy

BASOPHILS 00 % 0 - 2 Light Microscopy

PCV # 24.3 vol % 40 - 50 Calculation

M C V 88.0 fl 83 - 101 Calculation

M C H 31.2 pg 27 - 32 Calculation

M C H C # 35.4 % 31.5 - 34.5 Calculation

RDW-CV 12.8 % 11.6 - 14.0 Histogram

RDW-SD 41.4 fl 39.0-46.0 Histogram

RBC COUNT # 2.76 millions/cumm 4.5 - 5.5 Impedence

PLATELET COUNT 2.27 lakhs/cu.mm 1.5-4.1 Impedence


LIPID PROFILE ON 25/1/24

Total Cholesterol 155 mg/dl Child : Desirable
<170
Borderline high
170 - 199
High
>199
Adult : Desirable
<200
Borderline high
200 - 239
High
>239
CHOD/POD

Triglycerides 92 mg/dl 0 - 150 GPO-POD With
ESPAS

HDL Cholesterol # 36.7 mg/dl 40 - 60 Direct Enzymatic

LDL Cholesterol 82.8 mg/dl. 0 - 100 Direct Enzymatic

VLDL 18.4 mg/dl 12-40 mg/dl Direct Enzymatic


24 HR URINE CREATINE 

Urinary Creatinine 0.8 g/day Men:0.8-1.8 g/day Women:0.6-1.6 g/day

URINARY PROTEINS (24 HOURS)
24 HOURS
URINARY
PROTEIN
943 mg/day. <150 mg/day
24 HOURS URINE
VOLUME
2,300 ml

URINE PROTEIN / CRETININE RATIO Provisional
Test Result Units
SPOT URINE
PROTEIN
189.5 mg/dl.
SPOTURINE
CREATININE
7.2 mg/dl.
RATIO 2.63

 

2D ECHO ON 24/01/2024

EF 40%

LEFT ATRIUM  DILATED

LEFT VENTRICLE MILD DILATED , RWMA+ LAD AKINETIC TERRITORY , MILD LVH

IVC DIALATED, NON COLLAPSING

MODERATE MR +,  TRIVIAL AR+,  MODERATE TR+ WITH  PAH

 RWMA+ LAD AKINETIC TERRITORY , MILD LVH

NO AS/MS

MODERATE LV DYSFUNCTION+

NO DIASTOLIC DYSFUNCTION , NO PE

USG ABDOMEN DONE ON 25/1/24

RAISED ECHOGENESITY OF RIGHT KIDNEY

RIGHT PLEURAL EFFUSION

GRADE I FATTY LIVER

DX: HEART FAILURE WITH MIDRANGE EJECTION FRACTION 

TYPE II DIABETES MELLITUS

HYPERTENSIOIN

TRATMENT:

FLUID RESTRICTION <1.5LIT/DAY

SALT RESTRICTION <2 GM/DAY

INJ LASIX 20 MG IV/BD

TAB GLIMI M2 PO OD 1--0--0

TAB. DAGLIFOZIN 10 MG PO /OD HS 0--0--1

TAB DYTOR PLUS 10/50 OD 1--0--0

TAB DYTOR  10 MG PO/ OD HS  0--0--4PM

TAB CARDIVAS 3.125MG BD 1--0--1

TAB SALBITRIL + VALSARTAN 26/24  PO OD 0--1--0

TAB ECOSPRIN GOLD 75/75/10 PO OD 0--1--0

TAB PAN PO OD (BBF) 1--0--0

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