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E-LOG OF CASE


A 40 year old male patient came to casualty with chief complaints of bilateral pedal edema

Note : This is an online E-log book recorded to discuss and comprehend our patient's de-identified health data shared, after taking the patient's signed informed consent. Here in this series of blogs, we discus our various patient's 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 book also reflects my patient-centered online learning portfolio and your valuable inputs and feedbacks are most welcome through comment box provided. I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical data analysis " to develop my own competence in reading and comprehending clinical data, including clinical history, clinical findings, investigations and come up with most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

 CASE SHEET

This is a case of 42 year old male patient who  came to casualty with chief complaints of b/l pedal edema (pitting type)(l>r) since 15 days.

*This is an ongoing case . I' am in the process of updating and editing this ELOG as and when required

CHIEF COMPLAINT :

Bilateral  pedal edema since 15 days

HISTORY OF PRESENT ILLNESS :

  •  The patient was asymptomatic . For the past 2 days  the patient  complaints of  fever:- low grade intermittent , generalized weakness and sob grade 2-3 since 2 days                      
  •  Had an Ulcer over left malleoli 10 days back and  Got treatment in local hospital.                    
  • No h/o pain abdomen, vomiting, loose stools
  • No h/o cough, chest pain 
  • No h/o decreased urine output/ burning micturition and no other complaints 

HISTORY   OF    PAST   ILLNESS :

  • Not k/c/o diabetes mellitus, hypertension, asthma, epilepsy, cad, tuberculosis.
PERSONAL HISTORY:
  • Patient consumes 180ml of alcohol per day and khaini 2-3 per day since 20 years

FAMILY HISTORY :

  • No history of DM, Hypertension, CVA, CAD, Asthma, Thyroid disorders in the family

GENERAL EXAMINATION :

  • Patient is conscious, coherent, co-operative.
  • Icterus, Pedal edema present 
  • No pallor, cyanosis, clubbing, lymphadenopathy 

VITALS :

  • Temperature:- 98.6 F
  • Pulse rate: 110 bpm
  • Respiratory Rate : 18 cpm
  • BP: 100/70 mm Hg

SYSTEMIC EXAMINATION :

    CARDIOVASCULAR SYSTEM :  

     INSPECTION :

  •  Apex beat : visible
  • Diffuse shifted down and out 
      PALPATION :
  • Palpable p2+
  • Parasternal heave + (grade 3)
      ASCULTATION :
  • S1 , S2 heard , no murmurs.
                        VISIBLE EPIGASTRIC PULSATIONS
                                                        

                    VISIBLE APEX BEAT
                                                        

                     
 ABDOMINAL EXAMINATION : soft, tenderness
    
   RESPIRATORY SYSTEM  :                                                                                                         

  • Barrel shaped chest 
  • BAE+
  • Crepts + right sided lung fields


                                 BARREL SHAPED CHEST

                                                          




                                                
         P/A: soft , NT
        
         CNS: NFND

INVESTIGATIONS :
                        
                                           ECG
                                                                                                                                                                     



                                         CHEST X-RAY 


 LIVER FUNCTION TEST   


                
RANDOM BLOOD SUGAR



SERUM CREATININE

BLOOD UREA

SERUM ELECTROLYTES

HEMOGRAM





COMPLETE URINE EXAMINATION




PROVISIONAL    DIAGNOSIS  :       Heart failure with reduced ejection failure ? AKI (? prerenal )    CRS-1? b/l Pleural effusion , alcoholic liver disease, Right lower lobe pneumonia  and k/c/o cellulitis  

                                                       

TREATMENT:                                                                                                              


Treatment on 2/7/21: 
1)Fluid restriction   <1Lit / day 
2)Salt restriction <2gm /day 
3)Injection ceftriaxone  1gm IV /BD
4) Tab LASIX 40mg BD ( 8am to 4pm) 
5) Tab MET-XL 12.5 mg BD
6) BP PR temp spO2 monitoring 
7) Tab AZITHROMYCIN 500mg OD 
8) Tab ECOSPIRIN -AV 75/20 mg OD

Treatment on 3/7/21 :
Same as on 2/7/21

Treatment on 4/7/21: 
1)fluid restriction <1lit/day 
2)salt restriction. <2gm/day 
3) Inj. ceftriaxone 1gm IV/BD 
4)Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP ,PR, temp ,spO2 monitoring 
9) tab DIGOXIN 0.25 mg stat 

Treatment on 5/7/21 : 
Same as on 4/7/21

Following are the links  which are helping me to understand the case better








                                   



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