30 year Male came to casuality with pedal edema and shortness of breath

30 years male with shortness of breath and pedal edema since 1 month

 This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

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- present

           S3 gallop heard

P/A - SOFT non tender , Mild hepatomegaly.

CNS- intact.










INVESTIGATIONS:















CHEST X RAY:




2 D echo

 



ECG



ULTRA SOUND REPORT:

 Fever chart:

Psychiatry opinion:


23/09/2021

PROVISIONAL DIAGNOSIS:

Anaemia Secondary to vitamin B12 defecinency with Thrombocytopenia . 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)Fluid restriction <1.5 L/day

7)i/o charting.

DAY 2:

Temp:101F

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

6)Fluid restriction <1.5 L/day

7)fever charting.

Soap notes
21/09/2021

Subjective- SOB subsided ,pedal edema present, fever spikes absent

Objective
Temp: Afebrile
Bp: 100/60 mm hg.
PR: 70bpm
GRBS: 109mg/dl.
Spo2:99%

Assessment
Provisnal diagnosis: Anaemia secondary to vit B12 deficiency with thrombocytopenia.

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)Fluid restriction <1.5 L/day
6)fever charting.

Soap notes
22/09/2021

Subjective- SOB subsided ,pedal edema present, fever spikes Present

Objective
Temp: 102F
Bp: 120/50 mm hg.
PR: 100bpm
GRBS: 112mg/dl.
Spo2:99%


Assessment
Provisnal diagnosis: Anaemia secondary to vit B12 deficiency with thrombocytopenia.

Plan of care:
1)Bp/PR/Temp 4th hrly
2)inj.Vit B12:1500mcg IV/OD
3)Inj.Lasix 40mg iv/BD
4)Inj.Neomol 1gm iv/sos if temp>101F
5)Fluid restriction <1.5 L/day
6)fever charting.
7) weight monitoring.
Soap notes

23/09/2021

Subjective- SOB subsided ,pedal edema present, fever spikes absent.

Objective
Temp: Afebrile
Bp: 120/70 mm hg.
PR:90bpm
GRBS: 117mg/dl.
Spo2:99%


Assessment
Provisnal diagnosis: Anaemia secondary to vit B12 deficiency with thrombocytopenia.

Plan of care:
1)Bp/PR/Temp 4th hrly
2)inj.Vit B12:1500mcg IV/OD
3)Inj.Lasix 40mg iv/BD
4)Inj.Neomol 1gm iv/sos if temp>101F
5)Fluid restriction <1.5 L/day
6)fever charting.
7) weight monitoring.


Soap notes
24/09/2021

Subjective- SOB subsided ,pedal edema reduced, fever spikes present

Objective
Temp: 100F
Bp: 110/70 mm hg.
PR:90bpm
GRBS: 114mg/dl.
Spo2:99%


Assessment
Provisnal diagnosis: Anaemia secondary to vit B12 deficiency with thrombocytopenia.

Plan of care:
1)Bp/PR/Temp 4th hrly
2)inj.Vit B12:1500mcg IV/OD
3)Inj.Lasix 40mg iv/BD
4)Inj.Neomol 1gm iv/sos if temp>101F
5)Fluid restriction <1.5 L/day
6)fever charting.
7) weight monitoring.

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