1801006100- LONG CASE

 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.



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.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.

CHIEF COMPLAINT:
A 42 year old male patient 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 cough, chest pain 
No h/o pain abdomen, vomiting, loose stools jaundice 
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 
He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and  khaini 2-3 per day for the past 20 years.

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, Icterus,cyanosis, clubbing, lymphadenopathy 

VITALS:
1.Temperature:- 98.6 F
2.Pulse rate: 110 beats per min , regular
3.Respiratory rate: 18 cycles per min
4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM

Inspection: 
•  Chest is barrel shaped, bilaterally 
symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•.  
JVP:Raised 
•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. 
•Antero-posterior diameter of chest :Transverse  
diameter of chest increased 
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line
•Parasternal heave present (Grade-3)
•Palpable P2 + 
 
Auscultation: 
•S1 S2 heard
•No murmurs


RESPIRATORY SYSTEM:
Inspection: 
•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 ICS lateral to MCL

Palpation:

•All inspectory findings are 

confirmed: 

Trachea is central, movements 

equal 

bilaterally. 

•Antero-posterior diameter of 

chest is more than

Transverse diameter of chest

•Apex beat felt in 6th intercostal 

space lateral to midclavicular line

•Vocal fremitus decreased in 

right IAA & ISA

Percussion: 

•Dull note heard in right IAA & 

ISA

•Resonant note heard in all other 

areas bilaterally

 

Auscultation: 

•Bilateral air entry present – 

Normal vesicular breath sounds 

heard

•Breath sounds decreased in right 

IAA & 

ISA

•Vocal resonance decreased in 

right IAA & 

ISA

•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

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

PROVISIONAL 

DIAGNOSIS : 

HEART FAILURE

RIGHT SIDED PLEURAL 

EFFUSION

COPD        

INVESTIGATIONS- 

Chest x ray 

Plueral fluid analysis

Volume -3ml

Appearance- clear

Colour- pale yellow

Total count- 10cells

DC= 100% L

RBC - nil

Others- nil

SERUM CREATININE 

1.1 mg/dl  ( normal 

0.9-1.3)

Blood urea - 21 mg/dl 

Hemoglobin - 11.3 

mg/dl

Usg findings -

right sided

PLEURAL 

EFFUSIONS  AND 

MILD 

ASCITIS

Ecg - 

2d echo 

                              

                              

2D ECHO:

 Moderate to severe TR+ 

with PAH : mild MR+ , 

trivial AR + 

Global akinetic , no AS/MS 

severe LV dysfunction.

No diastolic dysfunction, 

No LV clot. 

HFrEF with EF=27%

                              

FINAL DIAGNOSIS:

HFrEF ? 2° to CAD   

B/l 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

6) Tab Telma 20mg

7) BP PR temp and spO2 monitoring