70 year old with pedal edema and sob

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan 

A 70 years old male came to the opd with chief complaints of 

Bilateral pedal edema since 2 weeks.

Shortness of breath since 2 weeks 

Decreased urine output since10 days.

History of presenting illness 

Patient was apparently asymptomatic 2weeks back the he developed bilateral pedal edema which was gradually progressive extended up to knee and it is of pitting type.

He developed shortness of breath which was incidious and gradually progressive and of grade sob is intially grade 2 and at present progress to grade 4.

7 settings of dialysis was done.

History of loss of appetite and Nausea.

History of hypertension since 10 years.

No history of fever

No history of burning micturation 

No history of diarrhoea 

Past history

Not a known case of diabetes mellitus, Asthma,epilepsy leprosy,CVD.

Treatment history

NSAID abuse 

Personal history:

Diet : Mixed 

Appetite : Decreased 

Sleep : Normal

Bowel moments :Regular

Bladder -decreased urine output 

Addictions:chronic alcoholic since 30yrs.

                  Tobacco smoking since 40 years.

Family History:

Not significant 

General examination:

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: present(bilateral)

Vitals:

Temperature - 94*F

PR :- 104bpm

BP :- 100/80 mm Hg

RR:- 16cpm

Systemic examination:

CVS : S1S2 heard

CNS:No focal neurological deficit.

P/A: soft, non tender 

Respiratory system:

-Inspection:

Trachea -central

Chest appears bilaterally symmetrical and elliptical in shape

-Palpation:

Trachea central in position

Measurements 

AP diameter16cms

Transverse -26cms 

-Percussion                Right              Left

Supraclavicular          R                    R

Infraclavicular            R                    R

Mammary                   R                    R

Axillary                      D                    D

Suprascapular             R                     R

Infrascapular               D                    D

-Auscultation 

Decreased breath sounds at Axillary and infrascapular.

Diagnosis:

USG

Bilateral moderate pleural effusion with collapse of underlying lobes.

Provisional diagnosis 

Chronic renal failure with bilateral pleural effusion.

Treatment

*Injection lasix 40 mg iv BD
*TAB nodosis 50 mg po BD
*TAB shelcal 50 mg po BD
* TAB Nicardia 10 mg po BD
* Cap biod3 weekly once
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.