75 YEAR OLD MALE WITH SOB

 

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

Case:

A 75 year old male resident of  dorumpally
came to casuality with c/o bilateral pedal edema, decreased urine output, sob since 7 days

HOPI:
Patient was apparently asymptomatic 1 week back then he took covid 19 vaccine and he was fine on that day. Next day he  got fever sudden in onset, continuous, non progressive and  relieved on medication
Pt developed  bilateral pedal edema a week back and he went to a private hospital in nalgonda and they performed some tests and confirmed b/l renal failure 

Pt came to Kims casuality  3 days back with complaints  of  bilateral pedal edema    insidious  in  onset,pitting type  gradually progressive to b/l knee associated with decreased urine output  and sob grade 2 to grade 3 not associated with orthopnea,PND, palpitations, giddiness, sweating 
Nocturia +
No froathy urine, burning micturition 
H/o fever on and off since 15 years, low grade, intermittent, not associated with cough, cold,headache, chills and rigors 

 Past history:
 He is a k/c/o hypertension since 7 months and is on regular medication
Not a k/c/o Diabetes,asthma, TB, CAD
He has no similar complaints in the past
He underwent hernia surgery 20 years back 

Personal history:
He has mixed diet,  appetite lost since 15 days,  adequate sleep, regular bowel and bladder movements 
He is occasional alcoholic , he used to smoke 8 years back

General examination:
Pt is c/c/c 
Moderately built and nourished
Pt is oriented to time,place,person

No pallor, Icterus,cyanosis,clubbing, lymphadenopathy 
Edema: present 

Vitals :
Pt is c/c/c 
Temp- afebrile
Bp- 150/90mmHg
Pr-98 bpm
RR- 15cpm
Spo2- 100% on RA
CVS-S1,S2 +
RS-BAE+ NVBS
P/A- soft,non tender
         BS+
Rt Inguinal hernia present:
Rt Inguinal hernia swelling present since 1year
Swelling size :5*5cm
Visible impulse+
Cough impulse +
Reducible 


CNS- HMF intact

Provisional diagnosis: CRF with HTN

Investigations:

Hemogram-
HB- 9.0
TLC- 5000
PLT- 80,000/cu.mm 
N- 79 
L- 15
E- 02
M- 04
B- 00
RBS- 182

CUE:
Albumin- +
Sugars- nil
Pus cells- 2-4
Epithelial cells-  2-3
RFT:
Blood urea- 152
Sr.Creat - 10.1

Sr. Electrolytes:
Na- 143
K- 4.7
Cl- 98

LFT:
TB- 1.10
DB- 0.30
SGOT- 11
SGPT- 10
ALP- 223
TP- 5.9

Serum Fe- 68

ECG:

USG:-

Treatment:-
1) Fluid restriction < 1.4 L/day
2) Salt restriction  <2.4 gm/day 
3) Tab.Lasix 40 mg PO/BD
4) Tab.Nicardia 10 mg Po/Tid
5) Tab.SHELCAL- CT PO/OD
6) CAP BIO -D3 PO/OD
7) TAB.NODOSIS 500 MG PO/OD

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