78 YEAR OLD MALE , FARMER BY OCCUPATION CAME WITH SOB ON EXERTION, PEDAL EDEMA AND GENERALISED WEAKNESS SINCE 20 DAYS
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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.
78 year old male with farmer by occupation, resident of Annaram came with chief complaints of SOB on exertion, pedal edema and generalised weakness since 20 days
HOPI-
Pt was apparently asymptomatic 3 months back, then developed SOB which gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations.
Orthopnea (+)ve, PND (+)
Not h/o facial puffiness, no decreased urine output, no burning micturition
H/o fever on and off since 2 months
Past history-
Pt was diagnosed with dengue 1 month prior
K/c/o DM since 10 years, on T. Zoryl-m2 po/bd
K/C/O serizure disorder, on T. Carbamazepine 200mg po/od
Not k/c/o HTN, CAD, asthma, CVA, TB
No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena
Personal history-
Sleep adequate, appetite decreased, bowel movements irregular, bladder regular, occasional alcoholic, non smoker
General examination-
O/e- pt is conscious, coherent, cooperative with respect to place ,time and person
AFEBRILE
BP- 150/80mmgHg
PR- 81 BPM
RR-24cpm
SPO2- 99%
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
JVP(-)
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Salt restriction < 2.4g/day
TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)
TAB ZORY - M2 PO/BD
TAB ECOSPRIRIN - AV (70/20) PO/HS
TAB CARBAMAZEPINE 200mg PO/OD
BP-MONITORING 4th HRly
GRBS 6th HRly
8am-2pm-8pm
I/O CHARTING
TEMP CHARTING
SOAP Notes:
22/12/21
78/M
S- no fever spikes, c/o SOB, not passed stools
O-
BP- 120/70mmgHg
Pr- 81 BPM
Rr-24cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
I/o- 500/900
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi
P-
Fluid restriction <1.5l/day
Salt restriction <2.5gm/day
Inj LASIX 40mg iv/bd
T. Zoryl-m2 po/bd
T. Carbamazepine 200mg po/od
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
Daily weight monitoring
T. Ecospirin-AV (75/20) po/od
23/12/21
Ward
78/M
S- SOB decreased
O-
BP- 130/70mmgHg
Pr- 93 BPM
Rr-20cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l upto knees, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
26/12/21
S- SOB decreased
O-
BP- 130/90mmgHg
Pr- 95 BPM
Rr-20cpm
SPO2- 99% @ra
Severe pallor (++)
Pedal edema (+), b/l, pitting type
Clubbing (-)
CVS- S1, S2 heard,
RS- BAE(+VE), NVBS
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/day
2. Salt restriction <2.5gm/day
3. Inj LASIX 40mg iv/bd
4. Inj Nervigem 1amp in 100ml NS IV OD
5. Inj HAI
6. T. Carbamazepine 200mg po/od
7. T. Ecospirin-AV (75/20) po/od
8.Syp cremaffin 15 ml BD
9. Syp. Potchlor 10 ml in glass of water po/TID
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
28/12/21
S- SOB decreased
O-
BP- 120/70mmgH
Pr- 90 BP
Rr-18cp
SPO2- 99% @ra
pallor (+)
Pedal edema (+), b/l, pitting typ
Clubbing (-)
CVS- S1, S2 heard
RS- BAE(+VE), NVB
P/A- soft, non tender
A- HRef (EF- 35%) with anemia under evaluation with CAD with DM-TYPE2 with seizure disorder with b/l hydroureteronephrosis secondary to ?calculi
P-
1. Fluid restriction <1.5l/da
2. Salt restriction <2.5gm/da
3. Inj LASIX 40mg iv/b
4. Inj Nervigem 1amp in 100ml NS IV O
5. Inj HAI
6. T. Carbamazepine 200mg po/o
7. T. Ecospirin-AV (75/20) po/o
8.Syp cremaffin 15 ml B
9. Syp. Potchlor 10 ml in glass of water po/TI
Monitor vitals 4th hrly
GRBS- 6th hrly
I/o charting
Co