1801006198- LONG CASE
1801006198- 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.
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
55yr old male who is a resident of narketpally and vegetable vendor by occupation presented to the opd with chief complaints of
• shortness of breath 20 days back.
• swelling of both lower limbs back.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20 days back later he developed shortness of breath which was insidious in onset which initially on exertion now progressed to NYHA 4.
Patient also complains of pedal edema 10 days ago which was insidious in onset and gradually progressed till knees.
History of facial puffiness 7 days ago which resolved spontaneously.
No H/o fever,cough.
No H/o decreased urine output.
No H/o wheeze,hemoptysis,orthopnea,PND.
No H/o chest tightness.
HISTORY OF PAST ILLNESS:
Not a known case of Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Coronary Artery Disease, Epilepsy,Stroke.
PERSONAL HISTORY:
Diet- Mixed
Appetite - Normal
Bowel and bladder movements- regular
Sleep- disturbed .
Patient takes 90ml of alcohol daily for the past 10 yrs.
Chews gutka for past 15 yrs.
FAMILY HISTORY:
Not relevant.
GENERAL EXAMINATION:
After taking consent, patient was examined in a well lit room after adequately exposed.
Patient was conscious, coherent and cooperative.
Moderately built and nourished.
Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing - present,bilateral,pandigital.
Generalized lymphadenopathy- absent.
Pedal Edema- Grade 2 (till knees), bilateral,painless,pitting type.
VITALS:
Temparature- Afebrile.
Blood pressure -130/70 mmHg
Pulse rate -68 bpm, regular.
GRBS- 92mg/dl.
SYSTEMIC EXAMINATION:
Cardiovascular System:
Jvp raised
On inspection:
Chest wall shape- normal.
Precordial bulge- absent.
No dilated veins, scars, sinuses.
Apical impulse- seen.
Palpation:
Apical impulse-felt at 6th ics 2cm lateral to mid clavicular line.
Charecter- diffuse and sustain.
No pulsations, thril felt.
Percussion:
Right heart border normal
Left heart border - dullness noted from lft 2nd ics medial to parasternal to apex.
Ascultation:
Mitral area: s1 s2 heard, no murmurs.
Tricuspid area: s1 s2 heard,no added murmurs.
Pulmonary area: s1 s2 heard no added murmurs.
Aortic area: s1 s2 heard no added murmurs
RESPIRATORY SYSTEM EXAMINATION:
ON INSPECTION:
Chest is symmetrical.
Trachea is in midline.
No retractions, kyphoscoliosis.
No scars, sinuses and dilated veins.
All areas move equally and symmetrically with respiration.
Palpation:
Trachea - central
No tenderness, local rise of temparature.
Tactile vocal fremitus:
Right Left
Supraclavicular: present. Present
Infraclavicular : present. Present
Mammary. : Present present
Infra mammary: Diminished. present
Axillary. : Present present
Infra axillary. : Diminished diminished
Suprascapular. : Present present
Infrascapular. : Diminished present
Interscapular. : Present. present
PERCUSSION:
Right Left
Supra clavicular: resonant. resonant
Infra clavicular: resonant resonant
Mammary: resonant resonant
Infra mammary: DULLNESS. resonant
Axillary: resonant. resonant
Infra axillary: DULLNESS. DULLNESS
Supra scapular: resonant. resonant
Infra scapular: DULLNESS resonant
Inter scapular: resonant resonant
• No tenderness
Auscultation:
Right Left
Supra clavicular: NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: NVBS NVBS
Infra mammary: Diminished NVBS
Axillary: NVBS NVBS
Infra axillary: Diminished Diminished
Supra scapular: NVBS. NVBS
Infra scapular: Diminished NVBS
Inter scapular: NVBS NVBS
Vocal Resonance :
Right Left
Supra clavicular: Resonant Resonant
Infra clavicular: Resonant Resonant
Mammary: Resonant Resonant
Infra mammary: Diminished Resonant
Axillary: Resonant Resonant
Infra axillary: Diminished Diminished
Supra scapular: Resonant Resonant
Infra scapular: Diminished Resonant
Inter scapular: Resonant Resonant
No added sounds.
CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions intact
Cranial nerve examination:Normal
Sensory nerve examination: Normal
Motor nerve examination: Normal
Neck rigidity: absent
Kernigs sign: negative
Brudzinskis sign: negative
ABDOMINAL EXAMINATION:
soft,non tender.
No hepatomegaly.
Spleen is not palpable.
Bowel sounds heard.
PROVISIONAL DIAGNOSIS:
HEART FAILURE WITH BILATERAL PLEURAL EFFUSION.
INVESTIGATION:
Serum creatinine: 4.8mg/dl
Blood urea: 96 mg/dl
Chest x ray:
Findings:
Obliteration of right costophrenic angle.
Enlarged cardiac silhoutte.
Cardiothoracic ratio more than 0.5
Usg findings:
Bilateral grade 2 renal parenchymal changes.
Bilateral mild pleural effusion.
Dilated inferior vena cava and hepatic veins- congestive changes.
Color doppler 2d echo:
Left ventricle- global hypokinetic, moderate to severe dysfunction.
Right atrium,left atrium,right ventricle dilated
Diastolic dysfunction.
Inferior vena cava dilated,non collapsing.
Ejection fraction- 38%
Electrocardiogram:
FINAL DIAGNOSIS:
HEART FAILURE WITH REDUCED EJECTION FRACTION WITH BILATERAL PLEURAL EFFUSION.
TREATMENT:
1.Inj lasix 40mg iv bd
2.fluid restriction<1 lit/day and salt restriction.
3.Tab ecosprin po
4.Tab met xl 12.5mg po
5.Inj thiamine 200mg direct iv bd
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