A 34 years Male Patient With Chest Pain and Pedal edema.

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

CHEIF COMPLAINTS:-

Chest pain in epigastric region since 1week.

Pedal edema since 1week .

Cough with expectoration since 1week .(mucoid consistency,non blood stained, non foul smelling)

Decreased urine output since 1week. 

HISTORY OF PRESENT ILLNESS :-

Daily routine of the patient :

The patient used to get up at around 7/8 in the morning, used to have breakfast  (Rice) and then used to go to drive auto. He then returns home in the evening and then used to consume alcohol daily before eating which was around 180ml and then sleep at around midnight at around 1/2. 

His intake of alcohol has increased to 750 ml per day (which is due to family issues according to the patient) and stopped consuming food at night.

4 years back he started noticing swelling in his hind limbs and he couldn't walk properly and experienced tingling sensation in fingers and went to hospital where doctors did a lumbar puncture and collected CSF and said there is accumulation of fluid over there.They gave them medications and patient continued to take medicines for 5 months and later he stopped taking them. After this he again started having alcohol and lost appetite ,had no proper food

Eventually the distension and swelling subsided and the patient started drinking again.

HISTORY OF PAST ILLNESS :-

H/O  Pulmonary Tuberculosis 7yrs back.

No H/O Hypertension, Diabetes mellitus, Asthma, CAD,CVA.

Patient lost his consciousness ,fainted 5 years back and came to emergency  where cpr is done

PERSONAL HISTORY:-

Married 

Occupation-Auto Driver 

Appetite-normal 

Diet-nonvegeterian

Bowels-regular 

Micturition- abnormal 

No known allergies 

Addictions- non smoker,Alcoholic 

FAMILY HISTORY:-

no significant family history 

GENERAL EXAMINATION:-

no pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers or toes,  malnutrition,

dehydration.

VITALS:-

Temp- afebrile 

Pr- 84/min

Rr-22/ min

Bp-120/90 mm /Hg

Spo2- 98%

SYSTEMIC EXAMINATION:-

a)CVS - S1 S2 Positive 

b)Respiratory system  -BAE Positive 

c)Abdomen-soft, non tender,no palpable mass

d)CNS

    consciousness

    Speech- normal 

     Signs of meningeal irritation like neck           

      Stiffness, kerning 's sign- no

     Cranial system, motor system, sensory 

     system- normal.

 e)  no cerebral signs

INVESTIGATIONS:-

TREATMENT:-

Inj- Lasix-40mg/IV/BD

Inj- Thiamine-200mg in 100ml NS/IV/TID

Inj- Pan-40mg/IV/OD

Inj- Optineuron 1amp in 100ml NS/IV/OD

NEB with Duoline,Budecort,Mucomist 8th hourly

Syp- Grillinctus BM 10ml/PO/TID

Fluid restriction <2l

Salt restriction <4GM/DL

BP ,PR, SPO2 monitoring 6th hourly 

Tab-pulmocler PO/BD