70 years old male come with a complaints of bilateral pedal edema ,SOB and decreased urine output

[ LONG   CASE ]
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"

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
DATE OF ADDMISSION:- 17/01/2023

CHEIF COMPLAINTS:-
A 70year Old Male , farmer by occupation presented to OPD with chief complaints of bilateral pedal edema since 1 month , shortness of breath since 1 month and decreased urine output since 1 month .


HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 1 month back than he noticed bilateral pedal edema ,pitting type upto knee joint  since one month.Pedal edema is subsided on medication .Decreased urine output since 25 days 
SOB grade 2 initially it was grade 1 progresing into grade 2. Associated with loss of appetite and nausea
Not associated with loose stools,fever.
 

HISTORY OF PAST ILLNESS:-
 Patient was admitted on 24/12/2022 and he was on hemodialysis and during the course of time he developed type 1 ,2 respiratory failure and refractory pleural effusion. Patient was intubated and hemodialysis is done. On therapeutic pleural tap -transudate effusion. Patient was removed from ventilator and extubated.
Not known a case of asthma, TB, CAD, epilepsy.
Known case of HTN since 2 months .


PERSONAL HISTORY:-
Married
Diet - mixed 
Appetite :- lost 
Bowel  movements-Regular        
Micturition:- abnormal 
Sleep :- Adequate 
Addictions:-
           Alcohol - occasional
           Tobacco smoking - since 40 years
Farmer by occupation.


FAMILY HISTORY:-

 No significant family history .


GENERAL EXAMINATION:-

Patient is conscious, coherent, co-operative and well oriented to time and place .
Moderately built and nourished.
There are no signs of icterus ,cyanosis ,clubbing lymphadenopathy, pedal edema.
Pallor is present 
VITALS:-

Temperature- Afebrile 
Pulse rate- 103 bpm

Respiratory rate - 22cycles/min

BP- 140/90mm of hg

Spo2- 99%

GRBS -163mg/dl

SYSTEMIC EXAMINATION:-


•CARDIOVASCULAR SYSTEM
Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.

Palpation:-
S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation:-
Cardiac rate - 100 beats per minute 
No cardiac murmurs heard


•RESPIRATORY SYSTEM:-
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- crepts

 Inspection:-
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear to be decreased on right side and it's Abdominothoracic type. 
Apex beat is localised at 5th intercostal space
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations. 
No rib crowding ,no accessory muscle usage, no drooping of shoulder.

Palpation :-
All inspectory findings are confirmed
Trachea is in central position 
Apical impulse -present 2cms lateral to the midclavicular line
No dilated veins
Chest movements-asymmetric 

Percussion:-
Dullness in 5th intercoastal area
                                     Right.                     Left 
Supraclavicular.      Resonant.              Resonant 
Infraclavicular.             R                             R
Mammary                    R                              R
Axilllary.                        R                             R
Infraxillary                 dull                             R
Suprascapular.             R                           R
Interscapular.               R                             R
Infrascapular                R                             R

Auscultation:-
                                   Right.                 Left
Supraclavicular :-    NVBS.            NVBS
Infraclavicular:-       NVBS.             NVBS
Mammary. :-             NVBS.             NVBS
Axillary:-.                   NVBS.             NVBS
Infra axillary:-           Crepts          Crepts       
Supra scapular:-      NVBS            NVBS
Interscapular:-.        NVBS.             NVBS


GIT
Inspection 
Shape of the abdomen -scaphoid
Flanks- full
Umbilicus - central and inverted 
Sinuses and scars - not visible
No dilated veins
Palpation 
No local rise in temperature
No tenderness
No palpable mass
No organomegaly
Hernial orifice -normal
Free fluid - yes
No bruits
Liver not palpable
Spleen not palpable
Percussion:-
Shifting dullness positive
Auscultation:-
Bowel sounds heard


•CENTRAL NERVOUS SYSTEM 

Patient is conscious , coherent, cooperative and we'll oriented to time and place.
Speech- normal
No sign of meningitis 
Motor and sensory system- Normal
Cranial nerves- normal
Memory intact

INVESTIGATIONS:-
 18-01-2023
HEMOGRAM 
ABG
LFT
RFT

2D ECHO

19-01-2023


17-01-2023
18-01-2023
19-01-2023

PROVISIONAL DIAGNOSIS:-
CKD on MHD.with right heart failure and pleural effusion 
TREATMENT:
Tab lasix 40mg PO/BD
Tab cefixime 200mg PO/BD
Inj optineuron 1amp IV OD
Tab nodosis 500mg PO TID
Tab shelcal 500mgPO OD
Tab orofer XT PO OD
Neb duolin+mucomir 8th hourly
Neb budecort 8th hourly
Tab spironolactone 25mg PO OD


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