A 60 year old male with pedal edema and shortness of breath

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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 

Chief complaints:
Patient came with complaints of
Pedal edema since 1 year
Shortness of breath (Grade 2) since 15 days
Decreased urine output since 15 days

History of presenting illness :
Patient was apparently asymptomatic 2 years ago then he developed pedal  edema which aggravated on working throughout the day and Relieved on rest . He's started. Developing  Anasarca since 15 days Associatied with SOB GRADE 2 & decreased urine output .Facial puffiness present 

PAST HISTORY:
K/c/o HTN since 10years (on T. CLINIDIPINE 10mg PO OD)
Not a k/c/o DM, epilepsy, BA, TB
Personal history:
Regularly consumes toddy 
Smokes 10beedis per day

VITALS:
TEMPERATURE - 99.1
PULSE RATE - 87 BPM
BLOOD PRESSURE - 140/90 MM OF HG 
RESPIRATORY RATE - 19CPM
SPO2 - 97 % AT ROOM AIR

General examination
Patient is conscious coherent cooperative well oriented to time place and person
Pallor +
No Ictrus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 
PER ABDOMEN : DISTENDED, umblicus-inverted ,SOFT Non tender 
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
BILATERAL AIR ENTRY PRESENT,
CENTRAL NERVOUS SYSTEM : NAD
DIALYSIS SESSIONS:
1st- 29/03/2022
2nd- 31/03/2022
3rd- 2/4/2022
4th -5/4/22

INVESTIGATIONS:

On 29/3/22
on 31/3/22

Dialysis done 2/4/22
03/4/22








 ECG

2D ECHO:

 ULTRASOUND ABDOMEN &PELVIS
Provisional Diagnosis:
Chronic renal failure 
TREATMENT:
On 29/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID

On 30/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID

On 31/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID

On 1/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID

On 2/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID

3/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID
7)T.ECOSPRIN -AV 75/20 MG PO /OD


4/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID
7)T.ECOSPRIN -AV 75/20 MG PO /OD
8)SYP.POTCLOR 10ML PO/BD( IN 1 GLASS OF WATER )


5/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID
7)T.ECOSPRIN -AV 75/20 MG PO /OD
8)SYP.POTCLOR 10ML PO/BD( IN 1 GLASS OF WATER )

6/3/22
1)INJ. ERYTHROPOIETIN 4000 IU/SC WEEKLY ONCE 
2)INJ. PAN 40MG PO OD
3)T. LASIX 40MG PO TID
4)T. NICARDIA 10MG PO/TID
5)T.SHELCAL PO/OD
6)T. NODOSIS 500MG PO TID
7)T.ECOSPRIN -AV 75/20 MG PO /OD
8)SYP.POTCLOR 10ML PO/BD( IN 1 GLASS OF WATER )



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