70 yrs male with severe anaemia

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no: 33

I've 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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 70 yr old male who is a resident of suryapet has presented to the OPD with the chief complaints of

  • SOB on exertion since 10 days
  • Pedal edema since 10 days
  • Generalised weakness since 10 days
  • Abdominal distension since 10 days
History of Presenting illness:
Patient was apparently asymptomatic 3 months back then developed shortness of breath gradually progressed from Grade 2 to Grade 3. Associated with generalised weakness, abdominal distension and pedal edema,
orthopnea +
PND+
History of fever with chills on and off since 2 months
No history of chest pain, palpitations
No facial puffiness
No history of decreased urine output
No history of burning micturition

Past history:
Patient is a known case of Diabetes since 10 yrs and is on medication
Known case of seizure disorder and is on carbamazepine 200mg OD
Diagnosed with dengue 1 month back
Not a known case of Hypertension, Asthma, CVA, TB
No history of blood transfusions, surgeries

Personal history:
Diet- Mixed
Appetite- Good
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions- Occasional alcoholic (Stopped 3 months back)

Allergic history:
No history of known allergies

Family history:
No significant family history
No family history of Hypertension, Diabetes, TB, Asthma, Seizures

General Physical Examination:
Patient is conscious, coherent, cooperative
well oriented to time, place and person
well nourished and moderately built

Pallor- ++
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- +



Vitals:
Temperature- Afebrile
Pulse rate- 82bpm
Respiratory rate- 24cpm
Blood pressure- 150/80 mm/Hg
SPO2- 99%

Systemic Examination:

Cardiovascular system:
S1 and S2 sounds are heard
No abnormal murmers
Apex- 6th Intercoastal space

Respiratory system:
Bilateral air entry is present
Trachea is central
Normal vesicular breath sounds are heard
Dyspnoea is present
No adventitious sounds are heard

Abdominal Examination:
Shape of Abdomen is distended
Free fluid- +
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly

Central Nervous System:
No focal neurological deficits

Investigations:

CBP:
Hb- 7.3
PCV- 22.8
MIV- 65.7
MCH- 21.0
MCHC- 32.0
RDW-CV- 21.0
RDW-SD- 50.3
Platelet- 3.5 lakh
RBC count- 3.47
Reticulocyte count- 0.7%

Blood grouping and RH typing:
'A' Negative

Complete Urine Examination:
Albumin- Nil
Specific gravity- 1.010
Pus cells- 2 to 3
Epithelial cells- 2 to 3
RBC- Nil
Crystals- Nil
Casts- Nil

Liver function tests:
AST- 12
ALT- 16
ALP- 339
TP- 6.3
Albumin- 3.0
A/G- 0.78

Stool for occult blood- Positive

Serum Electrolytes:
Sodium- 140
Potassium- 3.1
Chloride- 90
Phosphorous- 2.9

Serum Iron- 80
Serum creatinine- 1.2
Serum urea- 44
Uric acid- 3.5

RBS- 70

LDH- 174

ABG:
pH- 7.52
pCO2- 32.8
pO2- 80.1
HCO3- 26.3

Lipid profile:
Total cholesterol- 146
Triglycerides- 173
HDL- 30
LDL- 90
VLDL- 34.6

Troponin 1- Negative

ECG


USG



COLOUR DOPPLER 2D ECHO
                                         


Provisional diagnosis:
Severe anaemia
IDA?
CKD?

Treatment:
Fluid restriction <1.52 L/Day
Salt restriction <2.5gm/day
Inj. LASIX 40mg IV/BD
TAB. ZORYL BD
TAB. Carbamazepine 200mg/BD
I/O- Charting
Daily weight monitoring
TAB. ECOSPIRIN OD













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