70 yr old Male patient
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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 competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
CHEIF COMPLAINS
C/O PEDAL EDEMA SINCE 15 DAYS DRY COUGH SINCE 15 DAYS
70 YEAR OLD MALE , CLINICALLY PRESENTED WITH Complains of B/L pitting type of pedal edema of grade 2 &dry cough since 15days.
HOPI
70-year-old male initially 20 days back had history of fever, high grade,intermittent and associated with chills.Reduced on medications.He had cheif complains burning micturition and reduced urine output,and dragging type of chest pain radiating to back and with sweating for which he sought for consultation and was diagnosed with dengue serositis and CAD: AWMI. CAG was done which showed LAD total occlusion s/p Inj.Tirofiban infusion for 12 hrs was given and patient was advised for primary PTCA, for which patient sought for consultation in another hospital which is Aarogyasri approved &then he was transferred to that hospital where two units of PRBC transfusion was done at an interval of two days in between. After first transfusion he had history of fever associated with chills, burning micturition and CUE showed 10 to 15 pus , blood C/S showed staph. haemolyticus.urine C/S showed Canada albicans and treated with antibiotics according to sensitivity, during his hospital stay for seven days.
Later he was discharged with medical management &advised to review after 2 weeks for PTCA in v/o elevated S.Creatinine (?AKI)
So now patient came to our hospital for further management. Presenting complaints were pedal edema &dry cough
PAST HISTORY:
N/K/C/O HTN/DM/epilepsy/asthma/CVA/TB.
PERSONAL HISTORY:
DIET: MIXED
APPETITE: NORMAL
BOWEL AND BLADDER: REGULAR NO ALLERGIES
ADDICTION: AlCohol consumption 90ml/day 3-4 days a week since 5 years
FAMILY HISTORY: NOT RELRVENT
GENERAL EXAMINATION:
PATIENT IS C\C\C
PALLOR +
NO CYANOSIS
NO CLUBBING
NO ICTERUS
NO LYMPHADENOPATHY
B/L PEDAL EDEMA + PITTING TYPE EXTENDING UPTO SHIN OF TIBIA
VITALS:
BP: 120\80MMHG
PR: 72BPM
RR: 18CPM
SPO2: 98% ON RA
SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: BAE+, B/L CREPTS+ , WHEEZE+
P\A: SOFT, NON TENDER
CAS: NAD
Investigation
2d ECHO:
MILD DILATED RA/RV
RWMA+ LAD TERRITORY AKINETIC - EF 48% MODERATE TR+ MILD AR + &MR+
RVSP = 55 MMHG
MILD LV DYSFUNCTION
DIASTOLIC DYSFUNCTION
USG ABDOMEN: BILATERAL GRADE 1 RPD GRADE 1 FATTY LIVER
Treatment Given
1)FLUID RESTRICTION <1.5 liters/day 2)SALT RESTRICTION <2 gms/day 3)INJ.LASIX 40mg/IV/BD
4)T.MET XL 25 mg/PO/OD
5)NEB with BUDECORT - BD DUOLIN-TID
6)T.MONIT GTN 2.6 mg/PO/BD 7)T.MUCINAC 600mg/PO/BD 8)T.TRIMETAZIDINE -MR 35mg/PO/BD 9)3-4 EGG WHITES/DAY 10)MONITOR VITALS &INFORM SOS Advice at Discharge
1)FLUID RESTRICTION <1.5 liters/day
2)SALT RESTRICTION <2 gms/day
3)INJ.LASIX 40mg/IV/BD
4)T.MET XL 25 mg/PO/OD
5)FORACORT INHALER 200 MDI SPACER 2 PUFFS/BD 6)T.MONIT GTN 2.6 mg/PO/BD
7)T.MUCINAC 600mg/PO/BD 8)T.TRIMETAZIDINE -MR 35mg/PO/BD 9)3-4 EGG WHITES/DAY
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