Case 7

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.



A 44 year male is presented to OPD with chief complaints of pain at arterial region of chest region, shortness of breath,bilateral pedal edema,decreased urin output since 10 days.


HISTORY OF PRESENT ILLNESS 

Daily routine of patient-:

The Patient is farmer by occupation who wakes up at 7am and is done with his breakfast by 9am then he goes to the field and does farming, he will have his lunch by 1pm and return home from field by 4pm then he used to relax and have his dinner by 9pm and sleep by 10pm-11pm.

Patient was apparently alright 10 days back then he develop sudden pain below the chest during night time.

Patient developed fever associated with chills 1 week back and was admitted in the nearest private hospital where he was diagnosed with typhoid and was treated there.

Patient complaints of bilateral pedal edema(pitting type) upto knee, facial puffiness, loss of appetite,  decreased urin output.


HISTORY OF PAST ILLNESS 

The Patient is a known case of diabetes and hypertension since 5 year.

No history of epilepsy, asthma, tuberculosis 


PERSONAL HISTORY 

Patient has loss of appetite 

Diet-mixed

Sleep- adequate 

Addiction-No


FAMILY HISTORY 

There is no similar complaint in the family members.


TREATMENT HISTORY 

Patient is on medication due to kidney problem.


GENRAL EXAMINATION 

Patient is conscious,coherent, co-operative and well oriented to time and place 

There is no sign of icterus, cyanosis, clubbing,lymphadenopathy.

 Bilateral pedal edema is present(pitting type)







VITALS

Temperature-febrile

Pulse rate - /min

Respiratory rate-/min

BP-100/50

SPO2-99%


SYSTEMIC EXAMINATION 

Thrills-No

Cardiac sound-S1,S2

Cardiac murmer-No

RESPIRATORY SYSTEM 

Dyspnoea-No

Wheeze-No

Position of trachea-Central

Breath sounds-Vesicular

ABDOMEN 

Shape of abdomen-scaphoid

No tenderness 

No palpable mass

No Free fluid 

No bruits

Liver and spleen- not palpable

Bowel sound-yes

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech-normal

Motor and sensory system-Normal


PROVISIONAL DIAGNOSIS

Heart failure



INVESTIGATION-:














TREATMENT

Day -1 

-salt restriction <2.4gm/day 

-fluid restriction <1lit /day 

-Tab TELMA   AM /PO /OD 

-Inj LASIX 40 mg IV/BD (if BP >110mg/hg ) 

-Inj PANTOP 40 mg IV/BD 

-Tab NODOSIS 550mg PO/OD 

-Tab SHELLAC 500mg PO/OD 

-Tab PLM 500 mg PO /SOS 

-Inj NEOMOL 100 ml /IV/SOS (if temp .>101degreeF )

-Temp charting 4th hrly 

-Inj PIPTAL 4.5gm IV /BD


Day-2

salt restriction <2.4gm/day 

-fluid restriction <1lit /day 

-Tab TELMA   AM /PO /OD 

-Inj LASIX 40 mg IV/BD (if BP >110mg/hg ) 

-Inj PANTOP 40 mg IV/BD 

-Tab NODOSIS 550mg PO/OD 

-Tab SHELLAC 500mg PO/OD 

-Tab PLM 500 mg PO /SOS 

-Inj NEOMOL 100 ml /IV/SOS (if temp .>101degreeF )

-Temp charting 4th hrly 

-Inj PIPTAL 4.5gm IV /BD

-Inj hai pxemeal s/c

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