60 YR OLD MALE WITH PEDAL EDEMA

 I am Soumya 5th semester student .

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CHEIF COMPLAINTS

Burning micturition since 4 month

Reddish urine since 4 months

Abdominal distention since 1 month

Bilateral lower limb swelling from 10 days

Not passed stools since 4 days

HISTORY OF PRESENT ILLNESS

Patient was apparently normal 11 years ago

- He developed Right knee pain following which he was diagnosed with ? Hematoma surgery was done ( No documents )

- 10 years back his elder son has financial mess with him under alcohol influence fought with him and he fell on rocks and had a spine injury following which he had weakness of all four limbs and urinary incontinence, Unable to walk following two months later with conservative management with egg and fish he regained his power gradually, over two months initially able to work with support later able to do his daily routine activities including farming

- Four years back patient developed gradual decrease in urine output and retention with abdominal discomfort and SOB when he was diagnosed with ? BPH /obstructive uropathy unknown surgical procedure was done (no documents available) for next two years he does not have any symptoms but thereafter he again developed thin stream of urine so he was put on foleys for 2 years changing at every 7 to 10 days.

- 1 year back H/o similar complaints of sudden weakness of all limbs and spontaneous recovery in 2-3 months

- Since 4 months body weakness, burning micturition, reddish urine

- Since 1 month abdominal distention

- Bilateral lowerlimb edema since 10 days ( pitting type )

- Not passed stools from 4 days but passing flatus

HISTORY OF PAST ILLNESS

No Diabetes ,Hypertension ,TB ,Asthma,Epilepsy ,CVD 
Chemo/Radiation Exposure - No
Surgical history - 
Surgery for hematoma at knee
? BPH / obstructive uropathy surgery 

TREATMENT HISTORY

 Had treatment for paralysis for 6 months 
  
FAMILY HISTORY

No significant family history
 
PERSONAL HISTORY

Mixed diet
Appetite normal
Micturition normal
No known allergies 
Alcohol: occasional
Smoking Tobacco for 15 years and stopped few years prior to paralysis

GENERAL EXAMINATION


  • O/E
  • Pallor: mild
  • Icterus: absent
  • Cyanosis: absent
  • Clubbing of fingers: absent
  • Lymphadenopathy: absent
  • Oedema of feet: present pitting type
      Vitals:
  • PR :80  bpm
  • Temp : afebrile 
  • RR : 20 cpm
  • BP : 190/100 mmHg
  • Spo2 : 99 at room air
  • GRBS : 108

SYSTEMIC EXAMINATION
 CVS: 
    Thrills: no
    Cardiac sounds:S1 ,S2 present 
    Murmurs : absent 
 RS:
    Dyspnea: No
    Wheeze: No
    Position of trachea: central
    Breath sounds: vesicular 
 Abdomen
    Shape of abdomen: distended 
    Tenderness: No
    Palpable mass: no
    Hernia orifices: normal
    Free fluid: present, gross, umbilicus slit like
    Bruits: no
    Liver :not palpable 
    Spleen :not palpable 
    Bowel sounds :Present 
    Genital and P/R examination : 
                    No anal fissures, fistula ,
                         Hard stool pellets + ,anal tone low
                          no palpable mass , prostatomegaly +



 CNS :
  • Conscious
  • Speech: slurred since 4 days 
  • Glasgow scale E4V5M6

  • Motor-                Rt.                      Lt
  1. Tone.    UL       Dec.                dec
                       LL.       Dec.               Dec
 
      2. Power.   
                      UL.            2/5.              3/5
                
                      LL   .         3/5               3/5       REFLEXES : Right Left

Biceps       -          +

Tricep        -          +

Supinator   -         +

Knee         -           +

Ankle       -            +
Plantars   +          +

       

PROVISINAL DIAGNOSIS

  HFpEF with CKD Quadriparesis secondary to ?? Trauma - compression myelopathy


 INVESTIGATIONS

11/8










12/8















13/8










14/8

                              

                                                                   





15/8








16/8










17/8



DIAGNOSIS

 HFpEF with CKD Quadriparesis secondary to ?? Trauma - compression myelopathy

TREATMENT PLAN

11/8/22
   1. Inj. LASIX 40 mg /IV/TID 
   2. Inj. PAN 40 mg /IV/ OD
   3. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   4. Tab. NODOSIS 500 MG /PO/BD
   5.Tab. OROFER XT /PO /OD
   6. Tab. SHELCAL 500 mg/PO/OD
   7.Tab. ECOSPRIN AV 75 /10 mg /OD/HS
   8.Salt & fluid restriction
   9.BP/PR/Temp 4th hourly monitoring

12/8/22 

 HFpEF with CKD Quadriparesis secondary to ?? Trauma - compression myelopathy

c/o BL lowerlimb weakness, abdominal discomfort present 

  • Pt - c/c/c
  • Temp 98.6 F
  • PR - 84 bpm
  • BP - 160/90 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard    
  • GRBS 84 mg/dl 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       
Stools passed 
Input /output - 600 /500 ml

   1. Inj. LASIX 40 mg /IV/TID 
   2. Inj. PAN 40 mg /IV/ OD
   3.Inj. ZOFER 4 mg / IV/SOS
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/HS
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting


13/8/22


 HFpEF with CKD Quadriparesis secondary to - compression myelopathy

c/o BL lowerlimb weakness, abdominal discomfort present 

  • Pt - c/c/c
  • PR - 80 bpm
  • BP - 150/80 mmHg
  • RS -  Bilateral air entry present 
  • CVS - S1 & S2 are heard    
  • GRBS 84 mg/dl 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       


   1. Inj. LASIX 40 mg /IV/TID  if BP >110 mmHg
   2. Inj. PAN 40 mg /IV/ OD
   3.Inj. ZOFER 4 mg / IV/SOS
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting


14/8/22
  

HFpEF with CKD Quadriparesis secondary to  compression myelopathy

c/o BL lowerlimb weakness, abdominal discomfort present 

  • Pt - c/c/c
  • PR - 83 bpm
  • BP - 160/90 mmHg
  • RS -  Bilateral air entry present
  • SpO2 99 % RA
  • CVS - S1 & S2 are heard 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       
Input/output - 1050 /1700 ml
stools not passed since 2 days
Flatus not passed since 2 days

   1. Inj. LASIX 40 mg /IV/TID  if BP >110 mmHg
   2. Inj. PAN 40 mg /IV/ OD
   3.Inj. ZOFER 4 mg / IV/SOS
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting
   13.Tab. CILACAR 10 mg /PO/OD


15/8/22

HFpEF with CKD Quadriparesis secondary to  compression myelopathy


  • Pt - c/c/c
  • Temp 98 F
  • PR - 72 bpm
  • BP - 160/100 mmHg
  • RS -  Bilateral air entry present
  • RR - 16 cpm
  • CVS - S1 & S2 are heard 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       
ENEMA GIVEN PREVIOUS DAY

   1. Inj. LASIX 40 mg /IV/TID  if BP >110 mmHg
   2. Inj. PAN 40 mg /IV/ OD
   3.Inj. ZOFER 4 mg / IV/SOS
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting
   13.Tab. CILACAR 10 mg /PO/OD
   14.Syp. LACTULOSE 20 ml/PO/BD
  SOAP WATER ENEMA


16/8/22
HFpEF with CKD Quadriparesis secondary to  compression myelopathy


  • Pt - c/c/c
  • Temp Afebrile
  • PR - 72 bpm
  • BP - 150/100 mmHg
  • RS -  Bilateral air entry present
  • RR - 16 cpm
  • CVS - S1 & S2 are heard 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       

   1. Inj. LASIX 40 mg /IV/TID  if BP >110 mmHg
   2. Inj. PAN 40 mg /IV/ OD
   3.Inj. ZOFER 4 mg / IV/SOS
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting
   13.Tab. CILACAR 10 mg /PO/OD
   14.Syp. LACTULOSE 20 ml/PO/BD
   

17/8/22

HFpEF with CKD Quadriparesis secondary to  compression myelopathy


  • Pt - c/c/c
  • Temp Afebrile
  • PR - 72 bpm
  • BP - 150/100 mmHg
  • RS -  Bilateral air entry present
  • RR - 16 cpm
  • CVS - S1 & S2 are heard 
  • P/A soft & distended
  • CNS 
    • Motor-                Rt.                      Lt
    1. Tone.    UL       Increased        increased
                           LL.       Decrease.   Decreased

          2. Power.   
                          UL.            1/5.              3/5
                    
                          LL   .         2/5               2/5
          3.Reflexes 
  •                             B       T        K       A       P
  •                    R        -       +2       -        -        
  •                   L        +2     +2      +2       +
       

   1. Inj. LASIX 40 mg /IV/TID  if BP >110 mmHg
   2.Inj. ZOFER 4 mg / IV/SOS
   3.Inj RANTAC 50 mg IV /BD
   4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD
   5. Tab. NODOSIS 500 MG /PO/BD
   6.Tab. OROFER XT /PO /OD
   7. Tab. SHELCAL 500 mg/PO/OD
   8.Tab. ECOSPRIN AV 75 /10 mg /OD/PO
   9.Salt & fluid restriction
   10. propped up position
   11.BP/PR/Temp 4th hourly monitoring
   12.strict I/O charting
   13.Tab. CILACAR 10 mg /PO/OD
   14.Syp. LACTULOSE 20 ml/PO/BD



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