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A 32 year old with pedal edema

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


A 34 year male patient  auto driver by occupation  came  to the opd with complaints of
Cough with expectoration since 1 week
Chest pain in epigastric region since 1 week
B/L pedal edema since 1 week
Shortness on breath on walking since 1 week
Decreased urine output since 1 week
Generalised weakness since 1 week


Patient was apparently asymptomatic 1 week back then developed cough with expectoration-mucoid in consistency, non blood stained, non foul smelling, developed pedal edema ,Bilateral,progressed from involving ankles to limbs (grade 1 to grade 3),pitting type




PAST HISTORY-
H/o quadriplegia 11 yrs back ?hypokalemia 
H/o palpitations ,HR-240bpm,defibrillation done 5years back
H/O TB 4 years back for which he was on ATT for 4 months
Not  a known case of DM,HTN,ASTHMA,EPILEPSY,THYROID DISORDERS 

PERSONAL HISTORY-
Diet-mixed
Appetite-normal
B &B movements- urine output decreased
Sleep-normal
Addictions-  h/o alcohol consumption since past 12 years ,started occasionally then started having alcohol (whiskey ,toddy)regularly since 5 years
AUDIT C score -9/12
Tobacco consumption since 5 years
GENERAL EXAMINATION-
Patient is conscious,  coherent, cooperative 
Moderately built and moderately nourished 
Oriented to time ,place and person
No signs of pallor,icterus,cyanosis,clubbing,koilonychia, lymphadenopathy 
VITALS AT ADMISSION:
Afebrile 
BP-110/70 mmhg
PR-78bpm
RR-18cpm








SYSTEMIC EXAMINATION-
CVS-
Inspection 
Shape of chest- symmetrical 
Trachea -central 
No scars ,sinuses ,dilated veins
JVP not elevated 
Palpation-
All inspection findings confirmed 
Trachea -central
Apex beat- left 4th intercoastal space

Auscultation -
S1,S2  heard 
No murmurs 

RS- normal Vesicular breath sounds heard 
No added sounds

CNS-
No facial asymmetry ,all reflexes are normal

GIT 
No hepatosplenomegaly,no ascites

Investigations
DIAGNOSIS 
Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB 

TREATMENT 4/5/22
1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml  PO/TID
6. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
7.FLUID AND SALT RESTRICTION


SOAP NOTES AMC DAY 1 
S- c/o productive cough 
B/l pedal edema
O-
Patient concious,coherent,cooperative 
No pallor, icterus ,cyanosis, koilonychia,lymphadenopathy 
Vitals -
Temperature-98.6F
BP-110/80mmhg
PR-75bpm
RR-17cpm
Spo2-99%RA
B/L pedal edema -pitting type 
Cvs-S1,S2 +,No murmurs 
RS-BAE+,NVBS+,No added sounds
CNS-NAD
P/A-Soft,non tender
A-Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB 
P-1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml PO/TID
6. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
7.FLUID AND SALT RESTRICTION


SOAP NOTES AMC DAY 2
S- c/o productive cough 
O-
Patient concious,coherent,cooperative 
No pallor, icterus ,cyanosis, koilonychia,lymphadenopathy 
Vitals -
Temperature-98.3F
BP-110/90mmhg
PR-65bpm
RR-17cpm
Spo2-99%RA
Cvs-S1,S2 +,No murmurs 
RS-BAE+,NVBS+,No added sounds
CNS-NAD
P/A-Soft,non tender
A-Right heart failure (cor pulmonale)??
With MOD -SEVERE PAH
with past h/o TB (used ATT)
ESR-06 mm/1st hr
AFB Sputum -negative
P-
1. INJ LASIX 40mg IV /BD
2.INJ THIAMINE 200mg IN 100ml NS IV/TID
3.INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1AMP IN 100ML NS IV /OD
5.SYP TERBUTALINE SULPHATE & BROMHEXIDINE HYDROCHLORIDE 10ml PO/TID
6.TAB ACEBROFYLINE &ACETYLCYSTEINE PO/BD
7. NEB WITH BUDECORT,DUOLIN,MUCOMIST 8th hrly
8.FLUID AND SALT RESTRICTION





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