69 yr male with decreased urin output and sob

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I have 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 diagnosis and treatment plan.

69 year old male came to the casualty with the 

CHIEF COMPLAINTS 

1. Decreased Urine output since yesterday.

2. Shortness of Breath.

HOPI: 

The patient was a daily wage labourer who stopped working 10 years ago, had complaints of pedal edema since 20 days , decreased Urine output since 3 days , Anuria since 1 day and shortness of breath since 1 day.

The patient was apparently asymptomatic 20 days ago, developed pedal edema which gradually progressed upto knee, pitting type. Went to local hospital and used some tablets after which he had polyuria but the pedal edema did not subside. Since today morning he developed Shortness of breath ( grade 4) and Anuria 

No complaints of chest pain , palpitations ,orthopnea ,PND ,fever, vomiting,loose stools. 

No complaints of giddiness 

Complaints of cough with sputum.

PAST HISTORY:

K/C/O DM since 5 years for which he was on Tab. Metformin. 

H/O Leg Trauma 1 year ago , fracture was operated and it lead to Non union. 

Bed ridden since 1 year , sits on his own but not able to work. 

H/O seasonal SOB since many years associated with wheeze, cough on and off.

PERSONAL HISTORY:

DIET: Mixed 

SLEEP: Adequate

BOWEL AND BLADDER: Regular 

ADDICTIONS : 

Alcoholic since 40 years ( 90 ml daily)

Beedi smoking - 2-3/ day daily since 40 years.

ALLERGIES : No 

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

Patient is concious, coherent and co-operative and oriented to time and place. 

PALLOR : Absent 

ICTERUS:Absent 

CYANOSIS:Absent 

CLUBBING:Absent 

LYMPHADENOPATHY:Absent 

EDEMA: B/L Pedal Edema ( pitting type ) upto knees .

VITALS:

Temperature: 98.9° F 

Pulse Rate : 96 Bpm 

RR: 21 CPM 

BP : 140/90 mm Hg 

Spo2 : 70 % on Room Air ,98% on 13 litres of O2 .

GRBS : 60 mg /dl.

Vitals :(day 3)

Temperature: 98.1° F 

Pulse Rate : 87bpm

RR: 21 CPM 

BP : 100/60

Spo2 :98% on 4 litres of O2 .

GRBS : 206

SYSTEMIC EXAMINATION:

CVS: 

No Thrills 

S1 and S2 - Heard 

No cardiac murmurs 

RESPIRATORY SYSTEM:

BARREL SHAPED CHEST 

BAE - PRESENT

B/L CREPTS - PRESENT

WHEEZE - present ( B/L infraclavicular, inframammary, intra axillary areas.)

ABDOMEN:

Shape of Abdomen- Normal 

Tenderness - present in umbilical area.

No palpable mass .

Normal hernial orifices.

Not palpable spleen and liver .

CNS:

Level of consciousness: Normal 

Speech : Normal 

No signs of meningial irritation 

Glasgow coma score: 15/15

INVESTIGATIONS:(DAY 1)

ECG:

CHEST XRAY:

SERUM IRON:

ABG:

LFT:

RFT:

RBS:

USG ABDOMEN:

XRAY KNEE AP VIEW:

PROVISIONAL DIAGNOSIS:

 ACUTE EXACERBATION OF  COPD with ? CAP (right upper lobe consolidation) 

Heart failure with preserved ejection fraction, Severe PAH, COR Pulmonale

CKD (? DIABETIC NEPHROPATHY)

HYPOGLYCEMIA SECONDARY TO OHA( Resolved)

DIABETIC since 5 years )

TREATMENT: (DAY 1)

1. Inj . Lasix 40 mg IV BD.

2 . Nebulization with DUOLIN AND BUDECORT - STAT 4th hrly .

3. Inj . HYDROCORT 100 mg IV STAT.

4. O2 inhalation 10 litres.

5. 25% Dextrose IV STAT.

6. SYP . ASCORYL 10ml PO/TID 

7. INJ . Pan 40 mg IV / OD.

TREATMENT (DAY 2):

1. Inj . Lasix 40 mg IV BD.

2. Inj Augmentin 1.2gm IV BD

3. INJ Pan 40 mg IV / OD.

4.Nebulization with DUOLIN AND BUDECORT 4th hrly .

5.SYP . ASCORYL 10ml PO/TID

6.O2 inhalation (to maintain spo2 >88%)

7. GRBS monitoring 2nd hrly 

8. Vitals monitoring 2nd hrly

9. Inj HAI s/c acc to grbs

TREATMENT (DAY 3):

1.Inj . Lasix 40 mg IV BD.

2. Inj Augmentin 1.2gm IV BD

3. INJ Pan 40 mg IV / OD.

4.Nebulization with DUOLIN AND BUDECORT 4th hrly .

5.SYP . ASCORYL 10ml PO/TID

6.O2 inhalation (to maintain spo2 >88%)

7. GRBS monitoring 2nd hrly 

8. Vitals monitoring 2nd hrly

9. Inj HAI s/c acc to grbs

69/M

Day 5 

S:

Pedal edema 

O: patient is concious, cooperative and coherent. 

Vitals :

Temperature: 97.7°F

Pulse Rate : 88bpm

RR: 25CPM 

BP : 120/70

Spo2 :98% on 4 litres of O2 .

Cvs- S1 S2+

RS- B/L AE+, ,crepts in right IAA ICA ISA

P/A- soft, NT

CNS- B/L NSRL

A:

ACUTE EXACERBATION OF  COPD with ? CAP (right upper lobe consolidation) 

Heart failure with preserved ejection fraction, Severe PAH, COR Pulmonale

CKD (? DIABETIC NEPHROPATHY)

HYPOGLYCEMIA SECONDARY TO OHA( Resolved)

DIABETIC since 5  years.

P: 

1. Inj . Lasix 40 mg IV BD.

2. Inj Augmentin 1.2gm IV BD

3. INJ Pan 40 mg IV / OD.

4.Nebulization with DUOLIN AND BUDECORT 4th hrly .

5.SYP . ASCORYL 10ml PO/TID

6.O2 inhalation (to maintain spo2 >88%)

7. GRBS monitoring 2nd hrly 

8. Vitals monitoring 2nd hrly

9. Inj HAI s/c acc to grbs