60 yr old male with b/l pedal edema

Rambai 

Roll no : 89 

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

  This is a case of 60 year old male farmer by occupation resident of Jununthala came with  complaint  of both upper and lower limb swelling since 20 days.

HOPI:  

patient was apparently asymptomatic until 20 days ago. He had outside food and after which he noticed facial puffiness and both upper and lower limb swelling for which he went to local hospital and took medication following which the facial puffiness subsided 3 days back , he went to a function and ate mutton which is salty at 3:30 pm ,on the same day ,again he developed facial puffiness and b/l pedal edema at 10:30 pm which is of pitting type  for which they went to local hospital the next morning and was referred to higher centre .  

H/0 hiccups, belchings, indigestion 3 days back when he had mutton 

 Pt also complains of SOB G-2 , aggravated on activity,relieved on taking rest 

H/o Fever  present which is of low grade,Intermittent ,without chills and rigor.

Patient also complains of sweating and palpitations since 3 days 

H/o  Nausea,  Giddiness present 

PAST HISTORY :

H/o similar complaints in the past (5 years ago ) 

K/c/o DM type 2 since 9 years on medication 

K/c/o HTN since 9 years on medication 

K/c/o tuberculosis 10 years back 

H/o Anemia 5 years ago

H/o CVA Acute infarct in B/L capsulathalamic regions and corona radiata on 07/2021

H/o pulmonary koch's 10 years ago 

TREATMENT HISTORY 

On Tab.GLICLAZIDE 60 mg since 9 years for Diabetes 

On Tab .OLMESARTAN ,CLINIDINPINE ,CHLORTHIAZIDE Since 9 years for HTN 

On Tab.bethasone 0.5 mg since 2 years for CVA 

PERSONAL HISTORY : 

Diet: mixed 

Appetite : normal

Bowel and Bladder:  regular 

Sleep : adequate 

Allergies : No allergies 

FAMILY HISTORY

Not significant

GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative 

Well oriented to time ,place ,person 

No pallor ,icterus , clubbing,lymphadenopathy 

B/l pedal present present 

Vitals: 

Temp- 98.4 F 

Bp- 130/80 mmHg 

PR: 84 bpm 

Spo2 - 98% at RA 

Cvs: s1,s2 heard 

Rs: BAE present ,NVBS

P/A: soft, non tender 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

Reflexes:

       R  L

B ++  ++

T ++  ++

S ++ ++

K ++  ++

A ++   ++

P Flexor Flexor 

INVESTIGATIONS 

HB- 7.8 

TLC - 8,100 

PLT  - 3.22

RBC - 2.79 

MCV - 86.7 

UREA- 141 

S.CREATININE - 6.7 

Na - 130 

K+ - 5.9 

Cl-  - 102 

I cal - 1.09 

CUE : 

ALBUMIN - ++

PUS CELLS - 3-4 

EPITHELIAL CELLS - 2-3 

RBC- NIL  

TREATMENT GIVEN : 

*T.ECOSPRIN 75 mg po H/S

*T. ATORVOSTATIN 10 mg po H/S 

* T.AMLODIPINE 10 mg po / od 

* T.LASIX 40 mg od ( if SBP is >120 mmHg ) 

* Inj.ERYTHROPOIETIN 4000 IU S/C 

* T.SHELCAL 500 mg od 

* T.OROFER  PO /BD