60M CCF CAD CKD acute exacerbation 7 days Chronic Alcoholic 13/10/2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. 


Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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.




 60 Y OLD MALE WAS BROUGHT TO CASUALITY WITH C/O SWELLING OF UPPERLIMBS; LOWERLIMBS AND FACE SINCE 1 WEEK

HOPI-
PATIENT WAS APPARANTLY ASSYMPTOMATIC 7 DAYS BACK THEN DEVELOPED EDEMA OF B/L UPPERLIMBS AND LOWER LIMBS AND FACE SINCE 1 WEEK PITTING TYPE;INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE 
H/O SOB 7 DAYS BACK GRADE 4 RELIEVED NOW
H/O WEAKNESS OF BODY INABILITY TO STAND AND WALK SINCE 7 DAYS
H/O ULCER OVER SACRAL REGION (BEDSORE GRADE II) SINCE 2 DAYS
C/O VOMITINGS 7 DAYS BACK , NONPROJECTILE , NON BILIOUS; WATERY;FOOD PARTICLES AS CONTENT
H/O FEVER 1 WEEK BACK RELIEVED ON MEDICATION 
NO H/O DECREASED URINE OUTPUT, CHET PAIN; PALPITATIONS 
NO H/O LOOSE STOOLS; PAIN ABDOMEN
PAST H/O - NO SIMILAR COMPLAINTS IN THE PAST
N/ K/ C/O DM; HTN; EPILEPSY; ASTHMA; TB;THYROID DISORDER

PERSONAL H/O
MIXED DIET
APPETITE- NORMAL
BOWEL AND BLADDER - REGULAR 
SLEEP - ADEQUATE
ADDICTIONS
ALCOHOL- REGULAR SINCE 25 YEARS
STOPPED 10 DAYS BACK
SMOKING 2 TO 3 CHUTTAS / DAY
STOPPED 10 DAYS BACK

FAMILY H/O - NOT SIGNIFICANT 

GENERAL PHYSICAL EXAMINATION
PT IS CONSCIOUS; COHER: COOPERATIVE 
MODERATELY BUILT AND NOURISHED 
PEDAL EDEMA -PRESENT
NO SIGNS OF PALLOR; ICTERUS; CYANOSIS; CLUBBING; GENERALISED LYMPHADENOPATHY
 
VITALS
TEMP- 98.7 F
BP-160/80
PR- 54 BPM
RR- 18 CPM
GRBS-158 mg/dl
SPO2- 99%RA

SYSTEMIC EXAMINATION-

CVS- S1, S2 HEARD, NO MURMORS
RS- NVBS+ , BAE +
P/A- SOFT, NON TENDER, NO ORGANOMEGALY 
CNS- NORMAL

INVESTIGATIONS 

DIAGNOSIS -
DILATED CARDIOMYOPATHY WITH 
EF - 54% SECONDARY TO ALCOHOL INTAKE WITH AKI ON CKD(RESOLVING) WITH GRADE II BED SORE WITH HYPOKALEMIA SECONDARY TO DIURETICS (RESOLVED)


TREATMENT 

1.FLUID RESTRICTION LESS THAN 
1 L/DAY
2.SALT RESTRICTION LESS THAN
 2 TO 3 G /DAY
3.FREQUENT POSITION CHANGE
4.INJ LASIX 40MG IV/BD
5.INJ THIAMINE 1 AMP IN 100 ML NS 
IV/TID
6.TAB.SPIRANOLACTONE 25 MG PO/BD
7.SYP.POTCHLOR 10ML PO/TID IN 1 GLASS WATER
8.TAB.NODOSIS 500 MG PO/BD
9.TAB PCM 650 MG PO/BD
10.TAB.VITAMIC C 500MG PO/OD

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