1801006110 - LONG 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 

Chief complaints:

A 70 years old male came to the opd with chief complaints of 

Bilateral pedal edema since 2 months.

Shortness of breath since 2 weeks 

Decreased urine output since10 days.

History of presenting illness:

•Patient was apparently asymptomatic 2months back the he developed bilateral pedal edema which was insidious in onset and gradually progressive extended up to knee and it is of pitting type.

•He developed shortness of breath which was insidious in onset and gradually progressive and of grade sob is intially grade 2 and at present progress to grade 4.(NYHA)

•History of loss of appetite and Nausea.

•History of hypertension since 10              years.

•No history of palpitations,chest pain and syncopal attack.

•No history of cough,hemoptysis,wheeze.

•No history of fever

•No history of burning micturation 

•No history of diarrhoea 

Past history:

Not a known case of diabetes mellitus, Asthma,epilepsy leprosy,CVD.

Treatment history

NSAID abuse since 5 years for fever and body aches.

Personal history:

Diet : Mixed 

Appetite : Decreased 

Sleep : Normal

Bowel moments :Regular

Bladder -decreased urine output 

Addictions:chronic alcoholic since 50yrs.

 Tobacco smoking since 40 years.

Family History:

Not significant 

General physical examination:

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

Moderately built and nourished.

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema: present(bilateral) with discoloration of skin.

Vitals:

Temperature - 94*F

PR :- 104beats per minute 

BP :- 100/80 mm Hg

RR:- 16cycles per minute

SpO2-82%

Systemic examination:

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat is shifted down and out.

No parasternal heave and thrills

Auscultation-

Apex beat heard at 6th inter coastal space lateral to mid clavicular line.

 S1 diminished in intensity.

Pansystolic murmur heard at mitral area.

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

Measurements 

AP diameter-16cms

Transverse -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

Inframammary          R                    R

Axillary                        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)

Central Nervous system:

No focal neurological deficit.

Per Abdomen:

 soft, non tender 

Provisional diagnosis 

 Heart failure with Chronic kidney disease.

Investigations:

Liver Finction test:

Total bilirubin-1.34mg/dl

Direct bilirubin-0.30mg/dl

SGOT-43IU/L

SGPT-27IU/L

Alkaline phosphate-358IU/L

Total proteins-4.8g/dl

Albumin-2.7g/dl

A/G ratio-33

Hemogram:

Hemoglobin-9.3gm/dl

Total count-12,800 cells/m3

Neutrophils-95%

Lymphocytes-62%

Eosinophils-0%

PCV-29.7 vol%

RDW-14.2%

Renal function test:

Urea-73mg/dl

Creatinine-4.2mg/dl

Calcium-7.5mg/dl

Sodium-131mEq/L

USG

Bilateral moderate pleural effusion with collapse of underlying lobes.

Final diagnosis:

Congestive cardiac failure with bilateral pleural effusion and chronic kidney disease 2* to NSAID abuse and Hypertension.

Treatment

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