1801006197- SHORT CASE.

 1801006197- 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 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.

A 55 year old male came to the opd with the chief complaints of shortness of breath since 22 days and swelling in the lower limbs since 12 days

HISTORY OF PRESENTING ILLNESS 

Patient is apparently asymptomatic 22 days back , from then he developed shortness of breath that was insidious in onset and gradually progressive from grade 2 to grade 4.

Patient also noticed swelling in the foot 12 days back that was insidious in onset and gradually progressed up to the knees.

He also noticed facial puffiness 9 days ago that resolved spontaneously.

There is no history of chest pain, palpitations, and sweating.

There is no history of chest tightness.

There is no history of decrease in the urine output.

There is no history of fever and cough.

There is no history of wheeze , hemoptysis, orthopnea, paroxysmal nocturnal dyspnea.

Past history 

He is not a known case of diabetes, hypertension, asthma, tuberculosis, coronary artery diseases , epilepsy, stroke.

Treatment history 

He used nsaids for the back pain for the past 3 years.

He is not allergic to any drugs or food.

PERSONAL HISTORY 

Diet :- mixed

Appetite :- good

Bowel and bladder habits :- regular

Sleep :- decreased and disturbed.

Addictions :- Gutka- for the past 15 years.

                         alcohol - daily 90ml for the past 10 years.

FAMILY HISTORY 

not significant.

GENERAL EXAMINATION 

Patient is examined after taking the consent.

Patient is conscious , coherent and cooperative and moderately built and moderately nourished.

Clubbing is seen, bilateral and pandigital.

Pedal edema till knees , bilateral , pitting type.

There are no signs of pallor , icterus , cyanosis and generalised lymphadenopathy.

 

JVP is raised.

Vitals

Temperature- afebrile 

Blood pressure- 130/79 mm of hg.

Pulse- 68bpm.

Respiratory rate- 22cpm.

SYSTEMIC EXAMINATION 

 

CVS

 Inspection:- 

shape is normal.

Apical impulse is seen.

No pulsations are seen.

Precordial bulge is absent.

Pectus cavinatum and excavatum are not seen.

Palpation:-

Apical impulse is felt in the left 6th intercostal space , 2cm lateral to the midclavicular line.it is diffuse and sustained.

No pulsations felt.

No thrills felt.

No dilated veins felt.

Percussion:-

Right heart border is normal.

Left heart border- dullness is noted from left 2nd intercostal space to Parasternal line to apex.

Auscultation:-

Mitral area- s1, s2 heard, no murmurs heard.

Tricuspid area - s1, s2 heard, no murmurs heard.

Pulmonary area - s1, s2 heard, no murmurs heard.

Aortic area -s1, s2 heard, no murmurs heard.

RESPIRATORY SYSTEM 

Inspection :-

Trachea appears to be central.

All areas move symmetrically with respiration.

No retractions.

No winging of scapula.

No scars, sinuses and dilated veins.

Palpation:-

Trachea is central 

No tenderness or local rise of temperature.

Tactile vocal fremitus.

             

                                               Right                  Left 

Supraclavicular                Present               Present

Infraclavicular                  Present               Present

Mammary                          Present               Present

Inframammary                 Diminished        Present

Axillary                              Present                Present

Infra axillary                     Diminished        Present

Suprascapular                   Present                Present

Infrascapular                     Diminished        Diminished

Interscapular                     Present                Present

Percussion 

Supraclavicular                  Resonant              Resonant 

Infraclavicular.                     Resonant            Resonant 

Mammary                             Resonant              Resonant 

Inframammary                    Dullness               Resonant 

Axillary                                  Resonant             Resonant 

Infra Axillary                        Dullness                Resonant 

Suprascapular                       Resonant             Resonant 

Infrascapular                         Dullness               Resonant 

Interscapular                        Resonant              Resonant 

Auscultation 

Supraclavicular                     Nvbs                 Nvbs

Infraclavicular                       Nvbs                 Nvbs

Mammary                               Nvbs                 Nvbs

Inframammary                      Diminished      Nvbs

Axillary                                    Nvbs                 Nvbs

Infra axillary                           Diminished     Nvbs

Suprascapular                         Nvbs                Nvbs

Infrascapular                           Diminished     Diminished

Interscapular                           Nvbs                Nvbs

No added sounds. 

CNS

Higher mental funtions are intact.

Functions of cranial nerves are normal.

Sensory and motor system are normal.

No signs of meningeal irritation.

PER ABDOMEN.

Soft and non-tender.

No organomegaly.

Bowel sounds are heard.

Provisional diagnosis

Heart failure with bilateral pleural effusion.

INVESTIGATIONS 

X-ray

Obliteration of the right side costophrenic angle.

Cardiothoracic ratio is more than half.

Ultrasound findings.

Bilateral mild pleural effusion.

Dilated IVC and hepatic veins show congestive changes.

Bilateral grade 2 renal parenchymal changes.

Colour doppler echo.

Left ventricle- global hypokinetic, moderate to severe dysfunction.

Right atrium, left atrium, right ventricle are dilated.

Diastolic dysfunction.

IVC dilated, non collapsing.

Ejection fraction-38%.

ECG.

Final diagnosis.

Heart failure with reduced ejection fraction with bilateral pleural effusion.

Treatment 

INJ. Lasix 40mg, iv bd.

Tab.ecospirin po.

Tab. Met so 12.5mg po.

INJ.thiamine 200mg direct bd.