1801006180 LONG CASE

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

A 42 year old male patient farmer by occupation was brought to casuality with chief complaints of bilateral lower limb swelling (l>r) since 15 days, and SOB since 2 days.

HISTORY OF PRESENT ILLNESS:

•Patient was apparently asymptomatic 15 days back & then he noticed bilateral lower limb swelling which was insidious in onset gradually progressing pitting type ( left more than right ) extending up to the knees.

•Patient also complaining of breathlessness since 2 days which is Grade 2 initially progressed to Grade 3-4 (nyha)associated with orthopnea & PND

No h/o palpitations. 

No h/o cough, chest pain 

No h/o pain abdomen, vomiting

No h/o decreased urine output/ burning micturition ,fever and no other complaints 

HISTORY OF PAST ILLNESS:

He is not k/c/o DM , HTN , Bronchial Asthma , Epilepsy CVA CAD 

PERSONAL HISTORY:

Diet – Mixed 

Appetite – Decreased 

Sleep – Decreased (wakes up in the night once )

Bladder & Bowel movements – Regular 

Addictions..He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and khaini 2-3 per day for the past 20 years.(2pack yrs) 

FAMILY HISTORY

 no relavant family history 

TREATMENT HISTORY - 

No relavant treatment history 

GENERAL EXAMINATION

Patient is conscious,coherent,cooperative

Thin built & moderately nourished 

Pedal edema is present 

No pallor,cyanosis, clubbing, lymphadenopathy 

Icterus is present. 

VITALS:

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min , regular normal volume and character

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg in right arm supine position

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM

Inspection: 

• Chest is barrel shaped, bilaterally symmetrical.

•. JVP:Raised 

• No scars or sinuses

•Apical impulse seen in left 6th intercostal space lateral to mid clavicular line. 

Visible apex beat

jvp

Palpation:

•All inspectory findings are confirmed: 

Trachea is central, movements equal bilaterally. 

•Antero-posterior diameter of chest :Transverse  

diameter of chest is 1:1(approx) 

•Apex beat felt in left 6th intercostal space lateral to midclavicular line

•Parasternal heave present 

 

Auscultation: 

•S1 S2 heard

•No murmurs

RESPIRATORY SYSTEM:

Inspection: 

. Upper respiratory tract: no halitosis, oral thrush, tonsillitis, deviated nasal septum, turbinate hypertrophy, nasal polyp

•Chest is barrel shaped, bilaterally symmetrical.

•Trachea is central 

•Movements are equal bilaterally

•Visible epigastric pulsations 

•No scars or sinuses

•Apical impulse seen in left 6th Intercoastal Space lateral to mid clavicular line

Palpation:

•All inspectory findings are confirmed: Trachea is central, movements equal bilaterally. 

•Apex beat felt in 6th intercostal space lateral to midclavicular line

•Vocal fremitus 

Tactile vocal fremitus      Right                 Left

Supraclavicular                Resonant          Resonant

Infraclavicular                  Resonant         Resonant

Mammary                          Resonant         Resonant

Inframammary             Resonant         Resonant

Axillary.                             Resonant         Resonant

Infraaxillary                 decreased     Resonant

Suprascapular               Resonant         Resonant

Interscapular                Resonant         Resonant

Infrascapular                  decreased       Resonant

Percussion: 

•Dull note heard in right Infra axillary area and & Infra scapular area.      Right                 Left

Supraclavicular                Resonant          Resonant

Infraclavicular                  Resonant         Resonant

Mammary                          Resonant         Resonant

Inframammary             Resonant         Resonant

Axillary.                             Resonant         Resonant

Infraaxillary                 dull               Resonant

Suprascapular               Resonant         Resonant

Infrascapular                dull           Resonant

Interscapular                  Resonant         Resonant

•Resonant note heard in all other areas bilaterally

 

Auscultation: 

•Bilateral air entry present – 

Normal vesicular breath sounds heard

•Breath sounds decreased in right Infra axillary area and & Infra scapular area. 

•Vocal resonance decreased in right Infra axillary area and & Infra scapular area. 

•Expiratory wheeze heard bilaterally. 

                                    

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. 

CENTRAL NERVOUS SYSTEM:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal irritation

•Motor and sensory system – Normal 

Power tone bulk normal in all four limbs

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

.

PROVISIONAL DIAGNOSIS : 

HEART FAILURE RIGHT SIDED PLEURAL EFFUSION WITH COPD

INVESTIGATIONS- 

Chest x ray. 

Plural fluid analysis

Volume -3ml

Appearance- clear

Colour- pale yellow

Total count- 10cells

RBC - nil

Others- nil

LIVER FUNCTION TEST

Total bilirubin 2.6mg/dl (0-1)

Direct bilirubin -1.35 mg/dl (0-0.2)

Sgot-75IU/L (0-35)

Sgpt - 31IU/L (0-45)

Alkaline phospatase -157 IU/L (53-128)

Total protiens 6.1 g/dl

Albumin 3.5

SERUM CREATININE 1.1 mg/dl  ( normal 0.9-1.3)

Blood urea - 21 mg/dl 

Hemoglobin - 11.3 mg/dl

ECG... 

Usg findings -

right sided PLEURAL EFFUSION

2D ECHO:

Moderate to severe TR+ with PAH : mild MR+ , 

no AS/MS severe LV dysfunction.

No diastolic dysfunction, 

No LV clot. 

HFrEF with EF=27%(normal 50-70%) 

                            

FINAL DIAGNOSIS:

Heart failure with reduced ejection fraction (27%)? 2° to CAD  Bilateral PLEURAL EFFUSION (R >L)

Copd 

      

Treatment : 

1) Fluid restriction <1lit/day 

2) Salt restriction. <2gm/day 

 3) Tab LASIX 40mg BD (8am to 4pm)

4) Tab MET-XL 25mg BD 

5) Tab ECOSPIRIN-AV 75/20 mg OD

7) BP PR temp and spO2 monitoring