71 year old with fever for 1 day, shortness of breath since 4 days and pedal edema since 4 days



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

 CASE PRESENTATION:  71 year old male agricultural labourer by occupation  was absolutely healthy 10 days back.  Later he had fever for 1 day, low grade,associated with generalised weakness

Abdominal distension since 3 days, shortness of breath since 4 days, orthopnea- grade 4. no history of seasonal variation.

B/L pedal edema since 4 days, pitting type. Adequate urine output.

Heaviness in chest since 3 days

Cough dry intermittently since 3 days 

Loss of appetite since 3 days

No complaints of nausea, vomitings, pain abdomen, cold , palpitations or sweating 

Past history: No history of similar complaints in the past

Total knee replacement surgery was done 8 years back.

Not a k/c/o of DM,HTN,CVA, CAD,Aasthama, Epilepsy.

GENERAL EXAMINATION:Pt was conscious,coherent,cooperative

Well built and moderately nourished

 
B/L grade 2 Pitting type of pedal edema +

No pallor,Cyanosis,icterus,lymphadenopathy,

VITALS: 

Temperature: 101F

Fever charting:


 Bp:130/80mmhg

Pr:160bpm 

Respiratory rate:16/min

Grbs:148mg/dl at the time of presentation 

spo2:95% at RA

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, no additional sounds or murmurs heard.

RS: Bilateral air entry decreased.

Grade 4 dyspnoea. 

Wheezing sound is heard

           


                       


CNS: HMF intact moror systems intact,

Cranial nerve functions intact 

Abdomen: distended, flanks full, umbilicus -a transverse slit.

INVESTIGATIONS:

X ray: 

Cardiomegaly with bilateral pleural effusion 

                  

Ecg 

Day 1

Ecg showing flutter on day 4


Ecg on last day

   


   2d echo


    LA dilated 4.5 cms

    RA dilated 4.23 cms

    LV? LAD mild hypokinesia

    RV dilated 4.30 cms

    IVC and MPA dilated

    Moderate MR /AR, severe TR with mode PAH

   Sclerotic AV

  Mild 2V systolic function 

  Diastolic dysfunction 

Sputum for culture sensitivity

                                                 

Blood culture and sensitivity:

  

           





Hemogram 



Lipid profile
        

Liver function tests

          


Renal function tests

         


Blood for malarial parasite:

        
         
Complete urine examination:

          


Dengue NS1 antigen Ig G and IgM Rapid test



USG CHEST:

Bilateral minimal pleural effusion with basal consolidatory changes 

USG ABDOMEN:
Hemangioma of liver

Simple cortical renal cyst


DIAGNOSIS: 

Persistent atrial fibrillation secondary to ? CAD

Viral pyrexia

Hemangioma of liver


Treatment:

Fluid restriction(1.5 l/day)

Amiodarone infusion was given on day 1 and day 2

Tab. Augmentin 625 mg/PO/ TID

Tab.pan 40mg/PO/BD

Tab. MVT/PO/BD

Tab.diltiazem sr 30mg/PO/TID

Syp. Tussex/PO/TID 5ml-5ml-5ml

Tab.PCM 650 mg/PO/SOS

Tab. Zofer 4mg/PO/SO

Thrombophobe ointment for L/A

PR/BP/SOS charting hourly

I/O charting 

Tab.Dabigatrin 150mg/PO/BD

Advice at discharge:

Fluid restriction 1.5L/ day

Tab. Augmentin625 mg/PO/TID for 5 days

Tab.pan 40mg/PO/BD

Tab.MVT/PO/BD

Tab.Amiodarone100mg PO/BD

Tab. Diltiazem sr 30mg/PO/TID

Syp. Tussex SOS

Tab. PCM 650 mg/PO/SOS


   



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