70F WITH DECREASED URINE OUTPUT AND FEVER

-

PT CAME WITH 

C/O FEVER SINCE 4 DAYS 

ASSOCIATED WITH CHILLS AND RIGORS

EVENING RISE OF TEMP PRESENT 

DECREASED URINE OUTPUT SINCE 4 DAYS

C/O ABDOMINAL DISTENSION PRESENT 

SOB SINCE YESTERDAY EVENING 


C/O PEDAL EDEMA AND FACIAL PUFFINESS 


HOPI:


PATIENT WAS APPARANTLY ASSYMPTOMATIC 4 DAYS BACK THEN SHE HAD FEVER FOR 1 DAY WHICH IS HIGH GRADE, SUDDEN ONSET, ASSOCIATED WITH CHILLS AND RIGORS RELIEVED BY TAKING MEDICATION. SOB(GRADE-2) SINCE YESTERDAY WHICH IS GRADUALLY PROGRESSIVE AND PROGRESSED TO GRADE-4 . NO ORTHOPNEA, NO PND


C/O PEDAL EDEMA WHICH IS PITTING TYPE


C/O ITCHY SCALY LESIONS ON DORSUM OF FOOT SINCE 1 YEAR


H/O DECREASED URINE OUTPUT


NO COUGH, COLD,


NO CHEST PAIN, PALPITATIONS, NO ABDOMINAL PAIN, NO NAUSEA, VOMITING, LOOSE STOOLS


PAST HISTORY:


K/C/O HTN SINCE 4 YEARS


NOT A K/C/O DM-II, TB, EPILEPSY, CVA, CAD


PERSONAL HISTORY:

MIXED DIET


SLEEP ADEQUATE


APPETITE NORMAL


BOWEL AND BLADDER MOVEMENTS NORMAL


ADDICTIONS- ALCHOHOL- DRINKS WHISKY 90ML DAILY, STOPPED 10 DAYS BACK


FAMILY HISTORY- NOT SIGNIFICANT


GENERAL EXAMINATION:


PATIENT IS C/C/C


NO SIGNS OF PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, ICTERUS




EDEMA OF FEET PRESENT


TEMP- 98.8F PR-110BPM RR- 32CPM


BP- 180/100MMHG


SPO2- 92% AT ROOM AIR


GRBS- 111 MG/DL


CVS EXAMINATION: S1S2 HEARD, NO MURMURS


RS EXAMINATION: BAE+, NO ADDED SOUNDS


P/A- SOFT, NON TENDER, BS +


CNS EXAMINATION: NFND

DIAGNOSIS 

HEART FAILURE WITH PRESERVED EJECTION FRACTION (1MONTH) WITH BILATERAL PLEURAL EFFUSION WITH CKD (1MONTH)

HYPERTENSION 4YRS


INVESTIGATIONS

HEMOGRAM 

BLOOD UREA 
 

P.SMEAR
S ELECTROLYTES
CUE
S creatinine 
CXR




Comments

Post a Comment

Popular posts from this blog

23y old female with facial puffiness and pedal edema

-
Image
  23 year old female resident of vutikodu farmer by occupation came to OPD with chief complaints : Facial puffiness (on and off) since 5 months. Bilateral Pedal edema (on and off) since 5 months  Shortness of breath (grade 2) since 5 months. Fatigue since 5 months.  History of presenting Illness: Patient was apparently asymptomatic 5 months ago.Then she developed facial puffiness which was insidious in onset and gradually progressive in nature ,aggrevated while working in farm and relieved on medications . Bilateral Pedal edema since 5 months which was insidious in onset, gradually progressive in nature, aggrevated while working in farm and relieved on medications.It is pitting type. Shortness of breath (Grade 2) according to NYHA classification since 4 months. Sequence of events:  Five months ago, patient developed facial puffiness, bilateral Pedal edema ,fever with chills and rigor .So she visited a near by hospital,took medication,but symptoms didn't relieve. La...
Read more

27 yr old male presented with stomach pain

-
Image
 27yr old male resident of vellanki Mason by occupation came with chief complaints of stomach pain since 2 days An episode of vomiting just before presentation HOPI: Patient was apparently asymptomatic 3days ago then he developed stomach pain in epigastric area which is insidious in onset pricking and shooting type of pain radiating to back (lumbar region) gradually progressive in nature aggregated on not having food and no relieving factors 7-8 episodes of non projectile and non bilious vomiting History of fever 10days ago  History of weight loss, loss of appetite, insomnia, fatigue  No complaints of chest pain, palpitations, SOB, headache, burning micturition,loose stools, giddiness SEQUENCE OF EVENTS PAST HISTORY He is known alcoholic since 5 years with a daily intake of 160ml No history of DM,TB, ASTHMA,HTN, EPILEPSY, THYROID DISORDERS, ALLERGIES  FAMILY HISTORY No relevant family history PERSONAL HISTORY  Diet mixed  Appetite reduced  Bowel and bl...
Read more

76 year old female with hemiballismus secondary to uncontrolled sugars

-
Image
  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 . Unit 1 Amc bed 1 DOA 22/5/23 A 66 yr old female ,residence of nalgonda came to the opd with c/o  Slurring of speech since 15days Involuntary movements of right upper limb si...
Read more