General medicine case-5

 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 patients 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 comment box is welcome.

Chief complaint:

A 55- year old male presented to the OPD with chief complaint of shortness of breath since 2 days.

History of present illness:

Patient was apparently asymptomatic 2 months back then developed pedal edema- pitting type grade-1 then gradually progressed to grade-2 over 10 days and to grade-3 over 15 days.

Past history:

The patient has a history of pulmonary koch's 21 years back and had ATT for 6 months.

Known case of hypertension.

No history of asthma, diabetes, epilepsy.

Personal history:

The patient has a mixed diet.

Appetite is normal.

Has adeequate sleep.

Bowel and bladder movements normal.

No history of smoking and alcohol consumption.

Family history:

No similar complaints in the family.

General Examination :

Patient is conscious, coherent and cooperative 

Moderately built

Pallor is present 

No cyanosis,clubbing,icterus,lymphadenopathy 

Pitting type of pedal edema is present.

Vitals:

Temperature: afebrile

Pulse rate: 120 BPM

Respiration rate: 16 cycles per min

BP: 160/80 mm/Hg.




Systemic examination:

CVS:

No thrills

S1 S2 +

No murmurs heard.


Respiratory system:

Dyspnoea present.

Expiratory wheeze is present in all areas 

Position of trachea: central

Breath sounds: vesicular


Abdomen:

Shape of abdomen: distended

No tenderness

No palpable mass

Hernial orifice: normal

Free fluid is present

No bruits

Liver: not palpable

Spleen: not palpable

Bowel sounds are heard


CNS:

Patient is conscious

Speech is present 

Reflexes are normal


Investigations:











Final diagnosis:

Nephrotic syndrome.

Treatment:

1) FLUID RESTRICTION <1 L/ DAY

2)SALT RESTRICTION <2g/ day

3)TAB LASIX 40 mg

4)TAB RAMIPRIL 5 mg PO/BD

5) TAB PAN-D PO/OD

6) TAB NODOSIS 500mg PO/BD

7) MONITOR WT AND Abd

GIRTH- DAILY

8) I/O CHARTING

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