1801006100 - SHORT 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 70year old came to the OPD with
Chief complaints of:
Bilateral pedal edema since 12days
Shortness of breath since 5days
HOPI:
Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and is of pitting type.
He also developed Shortness of breath which was initially grade 1 and progressed to grade 2 (nyha)
Associated with orthopnea
H/o loss of appetite since one week and nausea and vomitings three days back (3 episodes) non billious
No H/o- fever,burning micturation, diarrhoea decreased urine output
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,Upper limb edema
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
Percussion
Supraclavicular - Resonant on R&L
Infraclavicular - Resonant on R&L
Mammary - Resonant on R&L
Axillary - Dull on both right and left
Suprascapular - Resonant on R&L
Infrascapular - Dull on both right and left
Auscultation:
Decreased breath sounds at axillary and infrascapular region
CVS:
Inspection:
• Chest is bilaterally symmetrical.
•Trachea is central
•Movements are equal bilaterally
•. No parasternal haeve
JVP:Raised
•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
Auscultation:
•S1 S2 heard
•No murmurs
Per abdomen:
CNS:
•HMF - Intact
Provisional diagnosis:
Left heart failure ?with bilateral pleural effusion
Investigation:
Chest X-Ray:
*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.
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