60 yr old male with SOB since 15 days on and off

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.


A 60 yr old male came to the Casuality with the chief complaints of SOB since 15days on and off

HOPI:
Patient was apparently asymptomatic 15days back then he developed SOB(grade 4) Which was on and off. It is associated with pedal edema which is of pitting type.
SOB is associated with orthopnoea
It was not associated with PND, palpitations, Chest pain, syncopal attacks.

Patient also has a ulcer over left leg for which he went to hospital and is on regular medication there he was diagnosed to have CRF and is on regular medication.

2 months back he developed pedal edema for which he went to local hospital there he was diagnosed as B/L CRF and his basline creatinine was 4.5

PAST HISTORY:
History of seizures in past, CKD, COPD and severe anemia

PERSONAL HISTORY:
Diet:veg
Appetite:reduced
Sleep:adequate
Bowel and bladder:Regular
Addictions: alcohol since 40yrs Daily 90-180ml/day
                   Smoking 18-20 beedis/Day
Allergies:No known food or drug allergies

FAMILY HISTORY:
insignificant


GENERAL EXAMINATION
patient is conscious,cooperative and coherent and well orientes to time,place and person
He is.moderately built and moderately nourished

He was examined after taking consent

Pallor: present
Icterus: absent
Cyanosis: absent
Clubbing:absent
 lymphadenopathy:absent
Edema:B/L pedal edema pitting type

Vitals:
Pulse rate:96bpm
Bp:120/80mmhg
Temperature:afebrile
Respiratory rate:26cpm
SpO2: 88% at room air
            99% at 6L O2

SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
-position of trachea: central
-Auscultation: B/L Crepts are heard in IAA,ISA

Cardiovascular system:S1S2 heard
Per abdomen: soft non tender non distended
CNS: higher motor functions are intact


INVESTIGATIONS:
18/10/21 chest xray
Pitting edema
18/10/21 ABG

18/10/21 BLOOD UREA
18/10/21 serum electrolytes
18/10/21 serum creatinine
18/10/21 hemogram
18/10/21 CUE
18/10/21 LFT
18/10/21 Troponin-1
18/10/21 HIV 1/2 rapid test
18/10/21 Hbs-ag
18/10/21 AntiHCV Antibodies
Blood group
18/10/21 blood sugar random
2D ECHO

ECG
USG abdomen
SARS CoV 2
Treatment
Tab LASIX 40mg BD
Tab PANTOP 40mg BD
Fluid restriction less than 1.5L/day
Salt restriction less than 2g/day
Tab shelcal OD
Inj erythropoietin 4000 Weekly once
Tab orofer BD
Tab Ecospirin BD
Tab metxl 25mg OD
Tab hydralazine 25mg OD
Neb duolin 4th hourly
        Budecort 6th hourly

PROVISIONAL DIAGNOSIS
 chronic renal failure with confestive heart failure with reduced ejection fraction with uremic encephalopathy



















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