71 year old male with hypervolemia hyponatremia and hypokalemia

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.   

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.


CHIEF COMPLAINTS -


A 71 year old male, resident of Hyderabad presented with chief complaints of :


- White frothy urine since 15 days


- Pedal edema since 15 days







HISTORY OF PRESENT ILLNESS - 




Patient was apparently asymptomatic 15 days back when he developed pyuria that is insidious in onset and gradually progressive. 


It is associated with decreased urine output since 15 days and pedal edama that is of pitting type since 15 days. It is also associated with burning micturition.


It is associated with episodes of nocturia and constipation.


He has also developed facial puffiness since 5 days.


There is no history of fever, loin pain.


He is a known case of asthma since 50 years.


He has bilateral lower limb weakness since 8 months which was insidious in onset and gradually progressive, he has been using a walker to walk since then.


He also had an episode of COVID infection 2 years back following which he had to be hospitalized for 16 days.


Past history - 


Patient is a known case of bronchial asthma since 50 years and has been using salbitamol inhaler for 2-4 times a day.


No history of diabetes mellitus, hypertension, epilepsy, tuberculosis.


Personal history - 


Diet - Vegetarian


Appetite - normal


Bowel movements - Decreased 


Bladder - Decreased urine output


Sleep - Adequate


Addictions - None




FAMILY HISTORY - 


Not significant


Personal history:


Wakes up at 5'0clock and reads 


10'0 clock -breakfast


2'0 clock - lunch


4'0clock - tea


9'0clock- dinner


Diet: vegetarian


Sleep:adequate and drowsy


Appetite-Decreased


Urine output -decreased


Bowel and bladder movements - decreased 




Family history:


No significant family history




General examination:


Patient is conscious, coherent , but not coperative moderately built and moderately nourished.


Vitals:


Temp : afebrile 


PR: 92/min 


BP:. 130/80mmhg.


Sp02:. 99%


GRBS:. 182 mg/dl


No pallor,icterus,cyanosis, clubbing,lymphadenopathy


Bilateral pedal edema is present of pitting type. There is also wasting of muscle present in both the legs.


Systemic examination:

Abdominal examination - 

INSPECTION:

Shape – distended-uniform

Flanks – free

Umbilicus – Normal Position, everted, nodules absent

Skin – normal

Dilated veins – absent

Movements of the abdominal wall - normal

Hernial Orifices, cough impulse - Umblical hernia, present

External genitalia - normal

Renal angle - no tenderness


PALPATION:

No tenderness, temperature - normal

Liver - not palpable

Spleen - not palpable

Kidney - not palpable



Cvs: s1 and s2 heard ,no murmurs heard


Respiratory system: normal vesicular breath sounds heard.


Cns: no focal neurological deficit


                           R. L


      Tone: UL. N. N


                LL. N. N


Power:


               UL:. 5/5. 5/5


               LL:. 3/5. 3/5


Reflexes:


               B. T. K. A. P


    R. +. ++. -. -. FLEXOR


    L. +. ++. -. -. FLEXOR 


Dysdiadokinesia - not present 

Gait - not elicited


INVESTIGATIONS: 


Treatment:


3/1/23 


Inj piptaz 4.5gm iv tid


Inj.pan 40mg iv od


Inj pcm 1gm iv


Monitor vitals


Syrup citralka B6 10ml tid




4/1/23


Inj piptaz 4.5gm iv tid


Inj.pan 40mg iv od


NS@75ml/hr


Syp poikchlor 15ml tid


Inj.zofer od


Protein powder with100ml milk


Syp cremaffin 10ml


Nebulizer with budecort and ipratropium




5/1/23


Inj piptaz 4.5gm iv tid


Inj.pan 40mg iv od


NS@75ml/hr


Syp poikchlor 15ml tid


Syp cremaffin 10ml


Nebulizer with budecort and ipratropium




Differential diagnosis: 

Hypervolemic hyponatremia with hypokalemia secondary to nebulization

With cystitis, with umblical hernia

With grade 1 fatty liver

With paraperisis under evaluation 











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