A 63 y/o male with pedal edema

A 63 Y/O MALE WITH PEDAL  EDEMA SHORTNESS OF BREATH AND SCROTAL SWELLING

This is 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 is an ongoing case. This blog post will be updated regularly.

CHIEF COMPLAINTS

Pedal edema since 3 months 

Shortness of breath since 3 months[grade 2 to grade 3]

Scrotal swelling since 1 month

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 months back then he developed b/l pedal edema(pitting type) for which he went to near by RMP and got medication

Following which he had shortness of breath (grade 2 to grade 3)

No c/o Orthopnea, PND, chest pain, Palpitations

C/o Scrotal swelling (painless) 

HISTORY OF PAST ILLNESS

Not a known case of DM

Not a known case of HTN

Not a known case of Asthma

Not a known case of TB

Treatment history:

Not significant

Personal history:

Diet: Mixed 

Appetite: Normal

Bowel & Bladder: Regular

Addictions: Alcoholic since 25 years

Non-smoker

Family history:

Not significant

General examination:

NO Pallor

NO icterus

NO cyanosis

NO clubbing

NO lymphadenopathy

Edema of feet: present (b/l up to knee)

VITALS

BP: 80/60 mm/hg

PR: 98bpm, irregular

SpO2: 96% on RA

GRBS: 142mg%

SYSTEMIC EXAMINATION

CVS

S1,S2 Heard, no thrills and murmurs

JVP increased






Apex best:7th intercostal space(lateral and outward to midclavicular line)

Parasternal heave present (grade 2)

Respiratory

NVBS heard

Dyspnea present (grade 3 to grade 4)

Abdomen:

Shape of abdomen: Scaphoid

Tenderness: present in Rt Hypochondrium

CNS:

NAD

Provisional diagnosis:

HF with rEF with EF~20%

 DCMP with Global Hypokinesia

(?) Persistent A.Fibrillation with RVR

INVESTIGATIONS

ECG


COMPLETE URINE TEST

HEMOGRAM


XRAY



2D ECHO




TREATMENT

31-07-21

IV was given

HFvEF [EF=20%]

Dcmp i GLOBAL HYPOKINESIA

VITALS 

Afebrile

BP :80/60 mm Hg

PR = 114 beats/min IRREGULAR

CVS = S1 S2 +

RS = BAE + clear

GRBS : 133 mg/dl

P/A : soft


1] PROPPED UP POSTURE

2] INJ. LASVX 40 mg IV/BD

3]TAB MET 12.5mg PO/BD

4]FLUID RESTRICTION < 1 L/ DAY

5] SALT RESTRICTION < 2mg/DAY

6] TAB RAMIPRIL 2.5mg 

7]TAB ELOSPIRIN [75/40] POLLS

8]INJ THIAMINE 200mg IV 100 ml NS/IV/OD

9] SYP. CREMAFFINE 15ml 

9] BP/PR/SP O2 CHARTING AND HOURLY

10]STRICT I/O CHARTING

11] GRBS CHARTING

12] O2 INHALATOR IF SPO 2  < 99%


01-08-2021

IV was given

HFvEF [EF=20%]

Dcmp i GLOBAL HYPOKINESIA

VITALS 

Afebrile: 98.6 Farenhiet

BP :80/60 mm Hg

PR = 82 beats/min

CVS = S1 S2 +

RS = BAE + clear

GRBS : 133 mg/dl


1] PROPPED UP POSTURE

2] INJ. LASVX 40 mg IV/BD

3]TAB MET 12.5mg PO/BD

4]FLUID RESTRICTION < 1 L/ DAY

5] SALT RESTRICTION < 2mg/DAY

6] TAB RAMIPRIL 2.5mg 

7]TAB ELOSPIRIN [75/40] POLLS

8]INJ THIAMINE 200mg IV 100 ml NS/IV/OD

9] BP/PR/SP O2 CHARTING AND HOURLY

10]STRICT I/O CHARTING

11] GRBS CHARTING

12] O2 INHALATOR IF SPO 2  < 99%



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