-

 

A 55 YEAR OLD MALE WITH ANASARCA SECONDARY TO RIGHT HEART FAILURE

  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

 

    I've 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 a diagnosis and treatment plan

 

A 55y/M Barber by occupation came to OPD with Chief Complaints of :

 • Pedal Edema since 1 month

 • Abdominal Distension, Decreased Urine Output, Facial Puffiness since 1 month

 • SOB on exertion

 

 HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 month ago after which he developed 

 • Pedal edema -

  1. Started in both Lower limbs 
  2. Gradually progressive in nature & extended upto thigh and Scrotum
  3.  Pitting type

 • later patient developed Abdominal distension, facial puffiness, decreased U/O

 • He also complaints of SOB on exertion (grade 2)

 

No H/o Chest Pain, Palpitations, Orthopnea, PND, Jaundice, Hematemesis, Bleeding PR

 

 PAST HISTORY :

 • No H/o similar complaints in the past

 • Patient has swelling of left scrotum since 10y

 • Patient is not a k/c/o DM, HTN, Asthma, Epilepsy, CAD

 

 PERSONAL HISTORY :

 • Sleep Adequate

 • Appetite Normal

 • Diet Mixed

 • Bowel Regular

 • Bladder - Decreased U/O since 1 month

 • Addictions;

  1. - Chronic Alcohol Abuse since 8 years, 100 ml daily, last drank 2 days before the presentation. 
  2. - Chronic Smoker since 20 years, 1 pack of beedi for every 2 days. 

 

 FAMILY HISTORY :

No Significant Family History/of

 

GENERAL EXAMINATION :

 • Patient conscious, Coherent, Cooperative & Well Oriented to time, place, person

 • Examination was done in well light room after adequate exposure and Consent

 • O/E 

  1. Pulse 82 bpm
  2. BP 130/80 mmhg
  3. RR 22 cpm
  4. Temp Afebrile
  5. SpO2 99% on room air

 

 • No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy

     - Generalized Edema (Anasarca)

 






 LOCAL EXAMINATION :

CVS 

  • Lateral to Mid-clavicular Down and
  • line, Raised JVP Outward
  • Para Sternal Heave +nt
  • Apex 5th ICS 1cm

RS

  • Trachea Central
  • BAE +nt
  • Crepts in Right ISA, IAA

ABDOMEN

  • Distended with Flanks Full
  • Umbilicus Horizontal / Slit like
  • Non tender
  • Shifting Dullness +nt
  • No Signs of Organomegaly
  • Bowel sounds normal

CNS: NAD

 

 PROVISIONAL DIAGNOSIS : 

Anasarca Under Evaluation 

? CCF

 

 INVESTIGATIONS :

  1. CBP
  2. CUE
  3. Sr.Creat
  4. Sr.Urea
  5. LFT
  6. Urinary Protein- Creatinine Ratio
  7. USG Abdomen and Pelvis
  8. USG Scrotum
  9. CXR
  10. ECG
  11. 2D Echo

 











 DIAGNOSIS :

ANASARCA SECONDARY TO RIGHT HEART FAILURE WITH B/L HYDROCELE & B/L FANICULITIS

 

TREATMENT

  - INJ.LASIX 40mg IV/BD

Day 1 (30/06/2021

  1. INJ.OPTINEURON 1amp in 100ml NS OD
  2. FLUID RESTRICTION < 1.5l/day
  3. SALT RESTRICTION < 2gm/day
  4. Daily Abdominal Girth and Weight Monitoring
  5. I/O Charting

 

Day 2 (01/06/2021)

  1. INJ.LASIX 40mg PO/BD
  2. INJ.OPTINEURON 1amp in 100ml NS OD
  3. TAB. OFLOX-OZ 200mg PO/OD
  4. TAB. PANTOP 40mg PO/OD
  5. TAB. PCM 500mg PO/SOS
  6. TAB. TELMA 40mg PO/OD (8AM)
  7. FLUID RESTRICTION < 1.5l/day
  8. SALT RESTRICTION < 2gm/day
  9. Daily Abdominal Girth and Weight Monitoring
  10. BP/PR/TEMP 4th Hourly. 

Comments

Post a Comment

Popular posts from this blog

30f with osteomalacia??

-
Image
A 30yr Old Female with ? Osteomalacia 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 I've 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 a diagnosis and treatment plan CASE A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of Pain in B/L Lower limbs since 2 years.  Patient wa
Read more

83 MOHAMMED WAHAAJ BIMONTHLY ASSIGNMENT

-
 BIMONTHLY  ASSIGNMENT (August)   BELOW IS THE LINK TO THE QUESTIONS ASKED TO US:- http://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html QUESTION 1:- Below is the link of the student for which I am giving my peer review. https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1 LONG CASE  :- A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema. REVIEW:- The Case is well presented and  p atient data has be deidentified and privacy is marked. C ase history is taken beautifully precisely taken including social ,educational and surgical  history which is way too essential to understand the socio economic back ground of the patient and helpful in accurate diagnosis. FINAL DIAGNOSIS : - Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis. Dilutional Hyponatremia secondary to A
Read more

RIGHT HEART FAILURE SECONDARY TO COPD

-
Image
  under the guidance of Dr. Rishik (Intern) This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. 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 a diagnosis and treatment plan. CASE SCENARIO: A 52yr old patient came to the ward on 29 June 2021 with chief complaints of  right lower limb swelling, intermittent fever (alive and well), shortness of breath  since 3days, and  burning micturition  for 15 days. HISTORY OF PRESENTING ILLNESS The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee. No H/O trauma, thorn prick, nausea, vomiting c/o a small wound, watery discharge since 2 days Fever- 5days intermittent, low grade, a/w chill A light rise in temp sob on exertion -5days a/w cough- 1
Read more