67 M, BILATERAL PEDAL EDEMA

PREFINAL CASE REPORT.

NAME: Meghana.M

Roll no: 90

Batch: 2017



 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"





67 YEAR OLD MALE WHO IS A FARMER BY OCCUPATION CAME WITH C/O PEDAL EDEMA SINCE 6 MONTHS,


SOB GRADE-2 SINCE 2. MONTHS,

C/O LOW BACK ACHE SINCE 2 MONTHS

HOPI-

PT WAS APPARENTLY ASSYMPTOMATIC 6 MONTHS BACK ,THEN HE DEVELOPED INSIDIOUS ONSET OF  PEDAL EDEMA (B/L ,PITTING TYPE ). ASSOCIATED WITH
NYHA CLASS-2 SOB SINCE  2 MONTHS WHICH PROGRESSED TO CLASS-3,ASSOCIATED WITH PND SINCE  2 MONTHS

PT IS HAVING LOW BACK ACHEACHE SINCE 2 MONTHS,NOT RELIEVED ON TAKING MEDICATION,
FROM 1 WEEK PT COMPLAINTS OF LOW BACKACHE AGGREVATED,
AND WASN'T ABLE TO SIT OR STAND AND CAME TO HOSPITAL WITH CLASS-4 SOB

PAST H/O-
K/C/O COPD AND ON INHALERS SINCE 2 YEARS

NOT A K/C/O DM,HTN,TB


TREATMENT H/O-

NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS


PERSONAL H/O-

MARITAL STATUS-MARRIED

OCCUPATION-FARMER

APETITE -NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)

FAMILY H/O-
NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION-
PT C/C/C

PEDAL EDEMA PRESENT

On presentation:



30/03/2022: 




NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY


VITALS-
TEMP-101 F
BP-120/80 MM HG
PR-110 BPM
RR-28/min
SpO2-88% @ RA, 99,%@ 5 L OF O2
GRBS-133 MG/DL

SYSTEMIC EXAMINATION-

Respiratory system:
Inspection:
No tracheal deviation 
Chest bilaterally symmetrical
Type of respiration: abdomino thoracic.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- present.
Vocal fremitus- normal on both sides
Measurements:
Anteroposterior diameter- 21cm
Transverse diameter-30cm 
Ratio: AP/T- 0.7
Chest expansion: 2.5 cm

Percussion:                      
Supraclavicular            
Infraclavicular.         
Mammary cr
Axillary
Infraaxillary.           
Suprascapular.      
Infrascapula          
Interscapular. 

Right side and left side- resonant in above areas.

Auscultation:.            Right.             Left

Supraclavicular           NVBS              NVBS
Infraclavicular.      Crepitations        
Mammary                    NVBS                NVBS
Axillary.                         NVBS.            NVBS
Infraaxillary.           Crepitations.  Crepitations
Suprascapular.      Crepitations.  Crepitations
Infrascapula          Crepitations.  Crepitations
Interscapular. 

Cardiovascular system:
JVP- raised.
Auscultation: 
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Abdominal examination:
Abdomen distended, umbilicus- inverted
Soft, tenderness present
No organomegaly.






CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.                   LFT
BICEPS-.        1+.                      1+
TRICEPS-.      1+.                      1+
SUPINATOR- 1+.                       1+
ANKLE.        -. 1+.                       1+
KNEE-.            1+                         1+





INVESTIGATIONS-







SEROLOGY-
NEGATIVE

TROPONIN-I - NEGATIVE

ECG- 

     







2D ECHO-




USG-

DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



TREATMENT-

1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD



ORTHO REFERAL

SOAP UPDATES
27/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+, crepitations heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.                   LFT
BICEPS-.        1+.                      1+
TRICEPS-.      1+.                      1+
SUPINATOR- 1+.                       1+
ANKLE.        -. 1+.                       1+
KNEE-.            1+                         1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD

9.INTEEMITTENT CPAP 4TH HOURLY




SOAP UPDATES
28/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+, crepitations heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTERMITTENT CPAP 4TH HOURLY












SOAP UPDATES
29/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTEEMITTENT CPAP 4TH HOURLY


SOAP UPDATES
30/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:102bpm
BP:100/60 mm of hg
RR-14 cpm
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+, crepitations in expiration heard
P/A:SOFT,NONTENDER, BS +
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.     LFT
BICEPS-.        1+.       1+
TRICEPS-.      1+.       1+
SUPINATOR- 1+.       1+
ANKLE. -.       1+.       1+
KNEE-.            1+        1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTERMITTENT CPAP 4TH HOURLY

SOAP NOTES:
31/3/22


67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:102bpm
BP:100/60 mm of hg
RR-14 cpm
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+, NVBS heard
P/A:SOFT,NONTENDER, BS +
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.     LFT
BICEPS-.        1+.       1+
TRICEPS-.      1+.       1+
SUPINATOR- 1+.       1+
ANKLE. -.       1+.       1+
KNEE-.            1+        1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTERMITTENT CPAP 4TH HOURLY




Presently the pedal edema has decreased:





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