General medicine case-5

 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 problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input.

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

A 30 years male patient from  Suryapet ,presented to OPD with a complaint of pedal edema and shortness of breath since 1 month.

History of present illness:-

-Patient was apparently asymtomatic 1 month back .

- Patient developed pedal edema which is pitting type and shortness of breath from 1 month .

-Patient has abdominal pain and distension from 1 month .

-Abdominal pain is relieved by taking medication.

-Patient has cough from 20 days.

-Patient has fever  with chills from 3 days.

Past history:-

-Patient has history of decrease in blood (anemia) 5 yrs back  and recieved blood. (blood transfusion was done )

- No history of hypertension ,diabetes mellitus,asthama, epilepsy etc.

Personel history:-

Diet is mixed (patient is student ,stays in hostel, takes 1 meal per day)

Appetite is decreased

Sleep is adequate

Bladder movements- normal 

Bowel movements are regular

Addiction:-No history of alcohol inkake or smoking.

Family history:-

No history of similar complaints in family

General Examination:-

Patient is conscious,coherent and cooperative.

Pallor is present 

-Icterus is present 

Edema is present which is pitting type .

-Abdominal distension is present 

-No cyanosis and clubbing .

Vitals:-

Temparature :- Afebrile

Bp :- 110/50 mmHg

PR:-100beats per min

RR :- 20 cycles/min

Spo2:- 98

Systemic Examination:-

Cardiovascular system:-

S1,S2+.   No mururs 

 

Respiratory system:-

Bilateral air entry is normal .

Palpation /Auscultation:-soft,non tender,Mild hepatomegaly.

Central nervous system:-

No abnormality detected

Investigations:-

Chest X ray 

ECG

 

-Other investigations.                                        

Provisional diagnosis:-

Anemia secondary to vit B12 deficiency

With thrombocytopenia .

Right heart failure 

Treatment:-                                                      

1)Temp :- Afebrile

    Bp      :- 100/60 mmHg

     PR      :- 70 beats/min

      GRBS. :-109 mg /dl

       Spo2 :-99%

  Plan of care :- 

1)Inj.Optineuron 1amp in 100 ml 

2)Inj .vit B12:- 1500 mcgIV/OD

3)Inj.Lasix   :-40mg  IV/OD

4)Tab PCM. :-500mg /sos

5)Fluid restriction <1.5L/day

6)Fever charting 

Questions :- 

1) How does anemia cause pleural effusion?

2)How vit B12 deficiency  causes hepatomegaly?

3)why anemia patients doesnot develop kidney failure ?

4)what are the other conditions in which pedal edema is present