A 70Y Female with GENERALIZED EDEMA, ABDOMINAL DISTENTION AND SOB ON EXERTION since 1 MONTH

 26 December 2021

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 Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .

Patient and his/her attenders have been informed and their consent has been taken.

SNEHA JAJU

Roll no 148

70 year old F    C/o Generalized body swelling since 1 month.

Distension of abdomen since 1 month 

SOB on exertion since 1 month

HOPI

Patient was apparently asymptomatic 6 years back, then one day after having her food while walking to wash her hands she suddenly felt giddiness and fell down following which she was taken to near by RMP and referred to higher centre there, she was diagnosed to have  right femur fracture and Denovo HTN . Then she was taken to near by quack and pop cast was applied for left leg following which she had recovery. 

She used  anti hypertensives for 1 month then stopped, now since 1 month she developed generalized body swelling which is pitting type associated with distension of abdomen and SOB on exertion and loss of appetite.

No h/o chest pain, giddiness, palpitations

PAST HISTORY:

 Not known case of DM,CKD,CVA,CAD

TREATMENT HISTORY:

 Hypertensive(not on medication)

PERSONAL HISTORY: 

Appetite -  Lost 

Diet - Non vegetarian

Bladder and bowel movements - Regular

Sleep - No

No known allergies 

No addictions.

FAMILY HISTORY 

No DM,HTN, Heart disease, Cancer, TB, Asthama 

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative. Well oriented to time, place and person.

Mild pallor. No icterus, cyanosis, clubbing, lymphadenopathy.

Pedal edema - B/L pitting type.

Vitals

 Temp: afebrile 

PR- 88/Min    

RR- 20/Min

BP- 110/70 mmHg

Spo2 -96%at RA

SYSTEMIC EXAMINATION

CVS- No thrills, S1 S2 heard, no murmurs

RS- NVBS,  Crepitus present Bilaterally.

P/A - Distended, non tender, palpable mass Liver, free fluid present- Dull note on percussion, Shifting fluid present

CNS- NFND

Tone, power and reflexes are normal.

                           

INVESTIGATIONS: 

CBP- 

Hb- 12.     TLC- 9300.    Plt - 2.97

RFT-

U-31.   Cr.1.2.    Na+ 136.   K+ 4.0.   Cl- 100

CUE- 

pus cells-2-3 cells.   RBC- nil, sugar-nil, ALB- nil.

LFT:

TB-1.10.   DB- 0.42.     AST- 37.      ALT-21.    ALP- 180.     TP- 5.8.    Alb- 3.12

SEROLOGY- NEGATIVE.

PROVISIONAL DIAGNOSIS: 

DCMP Heart failure with moderate ascites.