58 yr old man

 58 year old man from mandepally presented with c/o B/L pedal edema since 3 months ,abdominal distention since 2 months ,facial puffiness since 2 months dyspnea on exertion since 1 month,frothy urine since 1 month ,cough with expectoration since 5 days and fever since 1 day 

Patient works as a farmer at mandepally and has been having B/L knee joint pains since 5 months for which he has been taking medications and B/L pedal edema extending upto knees since 3 months followed by abdominal distention and then facial puffiness and the dyspnea on exertion and also frothy urine since 1 month 

He has been complaining of cough with mild sputum expectoration associated with hemoptysis, non foul smelling and high grade  fever since 1 day 

No c/o hematuria,loin pain, pain abdomen, reduced urine output

No c/o chest pain,palpitations, dizziness, sweating 

He is alcoholic since 20 years 90 ml whiskey 3 times a week his last intake was 1 year back

O/E patient is conscious, coherent and cooperative 

Vitals 

Temperature:101 F

Pulse rate: 77 bpm

RR:24 cpm

BP: 130/70 mmhg

S/E 

Cvs: S1S2 heard 

Apex beat in 5th intercoastal space at midclavicular line 

RS: B/L inspiratory crepts in infraxillary area, and inframammary area, infrascapular area 

P/A :soft and non tender 

CNS: intact ,no focal deficits 

Investigations 

CBP

Hb:12.9 gm/do

TLC: 8800 cells/cumm

Plc: 1.85 lkhs/cumm

CUE

Albumin : nil

Sugar : nil

Pus cells: 4-5

Rbc: nil

Epithelial cells: 2-4

RFT

Urea: 45 mg/dl

Creatinine: 1.5 mg/dl

Uric acid : 6.3 mg/dl

Ph :2.3 mg/dl

K:3.4 meq/l

LFT

Tb: 0.94 mg/dl

Db: 0.18 mg/dl

AST: 34 IU/L

ALT:27 IU/L

ALP:104 IU/L

TP: 5.3 gm/dl

Albumin :3.1 gm/dl

Urine spot protein creatinine ratio 0.12

Urinary electrolytes

Na+ 218 mmol/L

k+ 10.8 mmol/L

cl- 128 mmol/L

                            Ecg


                 Chest X ray P/A view



Treatment 

Fluid restriction less than 1.5L/day

Salt restriction less than 2 gm/day

Inj Lasix 40 mg IV /BD

Inj Augmentin 1.2 gm IV/TID

Syrup Ascoril 10 ml /PO/TID with 1 glass of water

Tab Dolo 650 mg /PO/SOS

Temperature charting 

Inj Neomol 100 ml /IV SOS if temp greater than 102F

Inj Thiamine 1 amp in 100 ml NS/IV/BD










Popular posts from this blog

Image
 34yr old man , as a working driver presented  with difficulty in swallowing since 5am   Weakness in Right UL and LL since 5am   Deviation of mouth to left since 5 am  Slurred speech since 6am .  Pt developed sudden onset of  difficulty in swallowing while he tried drinking water followed by he suddenly developed weakness of rt upper limb and rt lower limb .  His attendant later observed deviation of mouth towards left side and slurring of speech.  H/o 1episode of GTCS 3years back though wt on treatment.  He has been an occasionally  alcoholic since 20years .  Not a k/c/o Htn ,Dm type2, Thyroid disorder,  Asthama.  No h/o any past surgeries.   On examination:  Patient was conscious coherent and cooperative.   Vitals:    Pulse : 108 bpm  Respiratort rate: 18 cpm  Temperature: 98.6 F  Blood pressure: 170/100 mm hg  Grbs-153 mg/dl  Spo2: 98% at room air  CVS: S1, S2 heard  Respiratory system: Bilateral air entry present, normal vesicular breath sounds heard, no added sounds heard  Per abd
Read more

15 yr boy with Paraplegia and a history of Fever

Image
This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's 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 on the comment box is welcome. Here is a case i have seen: A 15 year old boy presented to the Opd at 2pm with the complaints of Slippage of footwear since 6 months Difficulty in walking since 6 months  Difficulty to get up from bed since 6 months Patient is in his 8th grade at a government school at a local village.  His parents work as Masons at a local village. He has an elder brother who is studying degree and a younger sister who is in her 10th grade. He was apparently completely alright 6 years
Read more

bimonthly assessment january

Image
1.26 year old woman with complaints of altered sensorium since day,headache since 8 days,fever and vomitings since 4 days https://harikachindam7.blogspot.com/2020/12/26-year-old-female-with-complaints-of.html a. A 26 year old woman with complaints of Headache since 8 days Fever since 4 days Vomitings since 4 days Altered sensorium since 1 day 28 year old woman with 1. Hyponatremia secondary to SIADH 2. Tubercular meningitis 3. Acute infarct in the left thalamic region 4. SLE with multiple joint pains              b.      Hyponatremia Tb meningitis SLE  Sequence of events Tubercular   meningitis (TBM) is a rare condition in patients with systemic lupus erythematosus (SLE). The aim of this study is to describe the clinical characteristics, possible risk factors, and outcomes of SLE patients with TBM. On systematically reviewing medical records from10 SLE patients with TBM admitted to a hospital from December 2008 to December 2018. A total of 100 cases in the same period were randomly se
Read more