GENERAL MEDICINE E-LOG

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 case study was done under the guidance of Dr. Vamshi, Dr. Madhumitha

CHIEF COMPLAINT:

 42 year old male patient came to casuality with chief complaints of bilateral pedal edema (pitting type)(l>r) since 15 days, Fever and SOB since 2 days.

 HISTORY OF PRESENT ILLNESS:

The patient was asymptomatic 15 days back until he had bilateral pedal edema(pitting) extending upto shin of tibia.

He had an ulcer over left malleoli 10 days back followed by increased swelling of left lower limb.

From the past two days he complains of low grade intermittent fever with generalized weakness and shortness of breadth (grade 2-3).

No h/o pain abdomen, vomiting, loose stools

No h/o cough, chest pain

No h/o decreased urine output/ burning micturition and no other complaints 

HISTORY OF PAST ILLNESS:

Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis 

PERSONAL HISTORY:

He has been consuming alcohol 180ml daily and  khaini 2-3 per day for the past 20 years.

GENERAL EXAMINATION:

The patient is conscious

Icterus is present

Pedal edema is  present 

Absence of  pallor, cyanosis, clubbing, lymphadenopathy 

VITALS:

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM:

  • S1, S2 heard
  • No murmers
  • Apex beat visible
  • Diffuse shifted down and out
  • Palpable p2
  • Parasternal heave is present( grade 3)

  VISIBLE APEX BEAT

VISIBLE EPIGASRTIC PULSATIONS
JVP 



B.RESPIRATORY SYSTEM:

  • Barrel shaped chest
  • BAE +
  • Crepts + right sided lung fields

   BARREL SHAPED CHEST 
 
AP diameter-23cms, Transverse diameter- 23cms

                                    
C.EXAMINATION OF ABDOMEN:

  • Soft, non tender

D.CENTRAL NERVOUS SYSTEM:

  • No Focal Neurological Deficit

PROVISIONAL DIAGNOSIS : 

  HFref 2° to CAD    b/l PLEURAL EFFUSION

AKI ( ? prerenal )    CRS -1 

? ALCOHOLIC LIVER DISEASE

R. LOWER LOBE PNEUMONIA

? COPD 

LEFT LOWER LIMB CELLULITIS

         

INVESTIGATIONS:

Investigations on 1/7/21:

CHEST X-RAY
                                               

LIVER FUNCTION TEST 

SERUM CREATININE 

BLOOD UREA

                                                   
SERUM ELECTROLYTE 

HEMOGRAM

COMPLETE URINE EXAMINATION

                              
2D ECHO 


                                                    

                                                                       ECG

Investigation on 3/7/21:
                                                     
ECG: ATRIAL FIBRILLATION, Irregular RR interval, No P wave

Investigations on 5/7/21:
                                            
ECG 

HEMOGRAM

BLOOD UREA 

SERUM CREATININE 

SERUM ELECTROLYTES 

Investigation on 7/7/21:
                                            
ECG 



TREATMENT : 

Treatment on 2/7/21: 
1)Fluid restriction   <1Lit / day 
2)Salt restriction <2gm /day 
3)Injection ceftriaxone  1gm IV /BD
4) Tab LASIX 40mg BD ( 8am to 4pm) 
5) Tab MET-XL 12.5 mg BD
6) BP PR temp spO2 monitoring 
7) Tab AZITHROMYCIN 500mg OD 
8) Tab ECOSPIRIN -AV 75/20 mg OD

Treatment on 3/7/21 :
1)Fluid restriction   <1Lit / day 
2)Salt restriction <2gm /day 
3)Injection ceftriaxone  1gm IV /BD
4) Tab LASIX 40mg BD ( 8am to 4pm) 
5) Tab MET-XL 12.5 mg BD
6) BP PR temp spO2 monitoring 
7) Tab AZITHROMYCIN 500mg OD 
8) Tab ECOSPIRIN -AV 75/20 mg OD

Treatment on 4/7/21: 
1)Fluid restriction <1lit/day 
2)salt restriction. <2gm/day 
3) Inj. ceftriaxone 1gm IV/BD 
4)Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP ,PR, temp ,spO2 monitoring 
9) tab DIGOXIN 0.25 mg stat 

Treatment on 5/7/21 : 
1)Fluid restriction <1lit/day 
2)salt restriction. <2gm/day 
3) Inj. ceftriaxone 1gm IV/BD 
4)Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP ,PR, temp ,spO2 monitoring 
9) tab DIGOXIN 0.25 mg stat 

Treatment on 6/7/21 :
1)Fluid restriction <1lit/day 
2)salt restriction. <2gm/day 
3) Inj. ceftriaxone 1gm IV/BD 
4)tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP PR temp and spO2 monitoring
9) tab DIGOXIN 0.25 mg stat 
10) Inj. CLINDAMYCIN 600mg IV/TID .

Treatment on 7/7/21 : 
1)Fluid restriction <1lit/day 
2)salt restriction. <2gm/day 
3) Inj. ceftriaxone 1gm IV/BD 
4)tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD 
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP PR temp and spO2 monitoring
9) tab DIGOXIN 0.25 mg stat 
10) Inj. CLINDAMYCIN 600mg IV/TID .

Discussion: A case study on CRS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186522/
AKI in CRS-1: A systematic review:https://www.karger.com/Article/Fulltext/442300#ref10













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