30 years male with shortness of breath and pedal edema since 1 month
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AISHWARYA GANNOJI.
ROLL NO-35.
A CASE DISCUSSION OF PEDAL EDEMA AND SHORTNESS OF BREATH SINCE 1 MONTH
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.
CHIEF COMPLAINT:
Pedal edema since 1 month.
Shortness of breath since 1 month.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back then he developed pedal edema (pitting type) and shortness of breath ( Grade 2 )
Associated with
- Abdominal distension and abdominal pain since 1 month.
Abdominal pain relieved on taking medication.
- cough associated with whitish sputum since 1 month.
He had high grade fever since 2days associated with chills.
PAST HISTORY:
He had similar complaints 10 yrs back and workup for anaemia and bone marrow biopsy was done.
PERSONAL HISTORY:
Decreased appetite.
Diet - Non vegetarian. Patient stays in hostel and willingly started taking less food 1 meal /day. Skips breakfast.
Bowel and bladder - Normal
Micturition - normal
No addictions
GENERAL EXAMINATION:
Pallor - present
Icterus - present
Cyanosis, clubbing - absent
edema of feet -B/L pitting type
VITALS:
Temp -afebrile
bp - 110/50 mmHg
PR - 110 beats/min
RR - 20 cycles/ min
Spo2 - 98%
SYSTEMIC EXAMINATION:
RS - BAE +
CVS - Heart sounds (S1 and S2) are heard.
On auscultation- parasternal heave +
P/A - SOFT non tender , Mild hepatomegaly.
CHEST X RAY:
PROVISIONAL DIAGNOSIS:
Anaemia ( megaloblastic secondary to dietary deficiency)
Right heart failure.
TREATMENT:
DAY 1:
1)Bp/PR/Temp 4th hrly
2)Inj.Optineuron 1amp in 100ml
3)Tab.MVT PO/OD
4)Inj.Lasix 40mg iv/BD
5)Tab.PCM 500mg /sos
6)Inj.Ceftriaxone 1gm Iv/BD
7)Fluid restriction <1.5 L/day
8)i/o charting.
DAY 2:
Temp: Afebrile
Bp: 100/50 mm hg.
PR: 64bpm
GRBS: 121 mg/dl.
Spo2:98%
Plan of care:
1)Bp/PR/Temp 4th hrly
2)inj.Vit B12:1500mcg IV/OD
3)Inj.Lasix 40mg iv/BD
4)Tab.PCM 500mg /sos
5)Inj.Ceftriaxone 1gm Iv/BD
6)Fluid restriction <1.5 L/day
7)fever charting.
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