1801006126-SHORT CASE

1801006126-SHORT CASE

 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 

A 70year old came to the OPD with

Chief complaints of:

Bilateral pedal edema since 2months

Shortness of breath since 2 weeks 

HOPI:

Patient was apparently asymptomatic 2 months back then he developed bilateral pedal edema which was insidious and gradually progression, extended upto knee.

He also developed Shortness of breath which was initially grade 2 and progressed to grade 4(nyha)

Associated with orthopnea

H/o loss of appetite since one week and nausea three days back (3 episodes)

History of hypertension since 10years

No H/o- fever,burning micturation, diarrhoea 

No H/o cough, hemoptysis,fever,

No h/o chest pain,giddiness , palpitations, decreased urine output, syncopal attacks,

No h/o abdominal distension, jaundice,vomitings

Past history: 

Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD

Treatment history 

Not significant 

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-chronic alcoholic since 30years and Tobacco smoking since 40years.

Family history: Not significant 

General examination:

Patient is conscious,coherent,cooperative and well oriented with time,place,person

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,

lymphadenopathy 

Bilateral pedal edema is present pitting type .

Vitals:

Temperature: 98.4 degree Fahrenheit

BP-100/80mmHg

PR-104bpm

RR-21cpm

Grbs- 147mg/dl

Systemic examination:

Respiratory system:

Inspection-

Trachea-central

Chest appears b/L symmetrical and elliptical in shape 

Palpation-

Trachea central in position 

Measurements- 

AP diameter-16cms 

Transverse diameter-26cms    

Tactile vocal

Fremitus                   Right              Left

Supraclavicular          N                   N

Infraclavicular           N                    N

Mammary                   N                    N

Inframammary          N                    N

Axillary                        N                    N

Infraaxillary        Decreased bilaterally 

Suprascapular           N                    N

Infrascapular       Decreased bilaterally                  

Percussion           

                                  Right              Left

Supraclavicular          R                    R

Infraclavicular            R                    R

Mammary                   R                    R

InfraAxillary                      D                    D

Suprascapular             R                     R

Infrascapular               D                    D

R-Resonant,D-Dull)

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary               NVBS             NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary             Crepitations  heard              

Suprascapular        NVBS              NVBS

Infrascapular           Crepitations heard               

NVBS-Normal vesicular breath sounds heard

CVS:

Inspection: 

•  Chest is  bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•. No parasternal haeve 
•NO Visible epigastric pulsations 
• No scars or sinuses
•Apical impulse seen in left 6th 
intercostal space lateral to mid 
clavicular line


Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line

Para sternal heave not seen

Auscultation: 

•S1 S2 heard

•No murmurs

Per abdomen: 

•Scaphoid

•Visible epigastric pulsations

•No  engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present

CNS:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

Provisional diagnosis: 

Congestive cardiac  failure with bilateral pleural effusion 

Investigation:

Chest X-Ray:

Hemogram:

Hemoglobin-9.3gm/dl

Total count-12,800 cells/m3

Neutrophils-95%

Lymphocytes-62%

Eosinophils-0%

PCV-29.7 vol%

RDW-14.2%

USG:

Bilateral moderate pleural effusion with collapse of underlying lobes.

ECG - 

Blood sugar-80mg/d

Serum creatinine:1.4gm/dl

Blood urea - 21 mg/dl

FINAL DIAGNOSIS-  

heart failure with pleural effusion 

Treatment

*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.