GM Elog Case-5

RISHIK 

R No 37

A 55yr OLD MALE WITH ANASARCA SECONDARY TO RIGHT HEART FAILURE

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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

A 55y/M Barber by occupation came to OPD with Chief Complaints of 

 • Pedal Edema since 1 month

 • Abdominal Distension, Decreased Urine Output, Facial Puffiness since 1 month

 • SOB on exertion

# HOPI

Patient was apparently asymptomatic 1 month ago after which he developed 

 • Pedal edema -

- Started in both Lower limbs 

- Gradually progressive in nature & extended upto thigh and Scrotum

- Pitting type

 • later patient developed Abdominal distension, facial puffiness, decreased U/O

 • He also complaints of SOB on exertion (grade 2)

No H/o Chest Pain, Palpitations, Orthopnea, PND, Jaundice, Hematemesis, Bleeding PR

# Past H/o

 • No H/o similar complaints in the past

 • Patient has swelling of left scrotum since 10y

 • Patient is not a k/c/o DM, HTN, Asthma, Epilepsy, CAD

# Personal H/o

 • Sleep Adequate

 • Appetite Normal

 • Diet Mixed

 • Bowel Regular

 • Bladder - Decreased U/O since 1 month

 • Addicitions 

- Chronic Alcohol Abuse since 8 years, 100ml daily, last drank 2 daya before the presentation. 

- Chronic Smoker since 20 years, 1pack of beedi for every 2 days. 

# Family H/o 

No Significant Family H/o

# General Examination

 • Patient conscious, Coherent, Cooperative & Well Oriented to time, place, person

 • Examination was done in well light room after adequate exposure and Consent

 • O/E 

- Pulse 82 bpm

- BP 130/80 mmhg

- RR 22 cpm

- Temp Afebrile

- SpO2 99% on room air

 • No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy

- Generalized Edema (Anasarca)

# Local Examination

CVS 

- Raised JVP

- Apex 5th ICS 1cm Lateral to Mid-clavicular line, Down and Outward

- Para Sternal Heave +nt

RS

- Trachea Central

- BAE +nt

- Crepts in Right ISA, IAA

Abdomen

- Distended with Flanks Full

- Umbilicus Horizontal / Slit like

- Non tender

- Shifting Dullness +nt

- No Signs of Organomegaly

- Bowel sounds normal

CNS: NAD

# Provisional Diagnosis : 

Anasarca Under Evaluation 

? CCF

# Investigations:

CBP

CUE

Sr.Creat

Sr.Urea

LFT

Urinary Protein- Creatinine Ratio

USG Abdomen and Pelvis

USG Scrotum

CXR

ECG

2D Echo

# Diagnosis :

ANASARCA SECONDARY TO RIGHT HEART FAILURE WITH B/L HYDROCELE & B/L FANICULITIS

# Treatment

Day 1 (30/06/2021)

- INJ.LASIX 40mg IV/BD

- INJ.OPTINEURON 1amp in 100ml NS OD

- FLUID RESTRICTION < 1.5l/day

- SALT RESTRICTION < 2gm/day

- Daily Abdominal Girth and Weight Monitoring

- I/O Charting

Day 2 (01/06/2021)

- INJ.LASIX 40mg PO/BD

- INJ.OPTINEURON 1amp in 100ml NS OD

- TAB. OFLOX-OZ 200mg PO/OD

- TAB. PANTOP 40mg PO/OD

- TAB. PCM 500mg PO/SOS

- TAB. TELMA 40mg PO/OD (8AM)

- FLUID RESTRICTION < 1.5l/day

- SALT RESTRICTION < 2gm/day

- Daily Abdominal Girth and Weight Monitoring

- BP/PR/TEMP 4th Hourly.