1801006195 - LONG CASE

This is online E log book to discuss our patients de-identified health data shared after  taking his/her/guardians 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 patients clinical problems with collective current best evidence based inputs. This  e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

I’ve 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 . 

 A 45 old male patient auto driver by occupation came to the OPD with the 

CHIEF COMPLAINTS of

swelling in the both legs since 5days

Shortness of breath since 5days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5days ago and then he developed increased swelling in both lower limbs which was insidious in onset, gradually progressive ,pitting type,upto the ankles.

He also complains of shortness of breath which was insidious in onset,gradually progressive from grade 2 to grade 4 which aggravates on activity and relieves on taking rest. 

history of paroxysmal nocturnal dyspnea is present 3hours after patient sleeps and relieves when the patient arises

Patient also complains of fatigue on activity 

No complaints of facial puffiness . 

No H/o chest pain , palpitations

No complaints of confusion , altered mental status , lack of concentration , memory impairment .

No complaints of abdominal pain . 

No H/O cough , sputum , hemoptysis, chest pain. 

No H/O burning micturition, increased frequency of urine , decreased urine output

PAST HISTORY

History of similar complains in the past 7months ago for which he is undergoing hemodialysis twice a week

He is a known case of diabetic mellitus since 6years.also a known case of hypertension for which he is under medication

No history of tuberculosis, asthma, epilepsy, cardiovascular diseases 

TREATMENT HISTORY

Patient is taking insulin injections for diabetes 

Patient is taking Tab.clinidipine, Tab.furosemide,Tab metoprolol for hypertension 

 

PERSONAL HISTORY

Appetite-normal

diet -mixed 

bowel and bladder movements-regular

Sleep adequate

 no addictions & no allergies

FAMILY HISTORY

no similar complaints in the family.

GENERAL EXAMINATION

Patient is conscious,coherent & cooperative. Moderately built and well nourished , well oriented with time , place and person

Pallor present

Pedal edema present 

No cyanosis,icterus,clubbing, lymphadenopathy

Left eye

Right eye 

Pedal edema

VITALS

Temperature:98.6°f 

Pulse rate:82bpm, regular rhythm,normal volume, condition of the vessel wall normal,no radio radial delay,no radio femoral delay

Blood pressure:130/80mm of hg measured in left upper limb in sitting position 

Respiratory rate:18 cycles/min, regular,abdominothoracic type.

SYSTEMIC EXAMINATION

Cardio vascular system

JVP raised

INSPECTION

Trachea appears to be central 

Chest wall is bilaterally symmetrical 

Shape of precordium- normal 

No precordial bulge

No engored neck veins 

Apical impulse seen at 8th intercoastal space

No visible pulsations 

PALPATION

Trachea is central

Apical impulse felt at 8th intercoastal space 1cm lateral to mid clavicular line

No pulsations,parasternal heave,thrills

No dilated veins

PERCUSSION

Left heart border is shifted laterally 

right heart border is normal in location 

AUSCULTATION

Mitral ,tricuspid, aortic and pulmonary areas ausculated

s1 and s2 are heard

No murmurs

RESPIRATORY SYSTEM

Upper respiratory tract

Oral cavity,nose, pharynx normal

Lower respiratory tract

Chest is bilaterally symmetrical

No chest deformities

No scars,sinuses,dilated veins, nodules

Movements of chest normal

PALPATION

Apical impulse felt at the level of 8th intercostal space 1cm lateral to the midclavicular line . 

Trachea is central in position

expansion of chest is bilaterally symmetrical. 

Tactile Vocal fremitus

                                        Right                   Left

Supra clavicular:        normal       normal

Infra clavicular:          normal       normal

Mammary:                  normal        normal   

Axillary:                      normal          normal

Infra axillary:             normal       decreased

Supra scapular:         normal        normal

Infra scapular:           normal        decreased  

Inter scapular:           normal         normal

PERCUSSION 

                                                   right         left 

Supraclavicular.                 Resonant      Resonant

Infraclavicular                   Resonant      Resonant

Mammary.                           Resonant.    Resonant

Axillary.                               Resonant.        Resonant

Infraaxillary.                       Resonant.         Resonant

Suprascapular.                   Resonant      Resonant

Infrascapular                      Resonant       Resonant

Interscapular.                     Resonant Resonant

AUSCULTATION: 

Mild infra axillary creptations.

Vocal resonance is normal , No wheezing,stridor,pleural and precordial rub . 

PER ABDOMEN EXAMINATION: 

Inspection: 

Abdominal distension is present . Fullness of flanks is seen

Umbilicus is everted  

all quadrants are moving equally with the respiration, 

No visible pulsations,scars,sinuses,striae,stretched ,hernial orifices , No dilated veins on the abdominal wall . 

PALPATION : 

No local rise of temperature and tenderness over the abdomen .

No organomegaly

PERCUSSION : 

shifting dullness is present ,

No fluid thrill , 

No increase in the liver span . 

AUSCULTATION: 

Bowel sounds are heard . 

CNS EXAMINATION : 

Higher mental functions are normal .

All cranial nerves are intact

Motor system : 

1. Bulk : both right and left upper and lower limbs are normal . 

2.Tone : tone of both upper and lower limbs are normal . 

3. Power :                      

Right upper limbs 5/5

Left upper limbs 5/5

Right lower limbs 5/5

Left lower limbs 5/5

4. Reflexes : 

superficial reflexes are normal . 

Deep tendon reflexes : 

Biceps jerk  (+2)right      left (+2)

triceps jerk (+2) right.     Left (+2)

ankle jerk    (+2)right       left (+2)

knee jerk (+2) right.         Left(+2)

Normal gait and No involuntary movements.

 

SENSORY SYSTEM : 

crude touch , pain , temperature, fine touch , vibration , position sense are normal .

 

Cerebellar signs : 

Nystagmus , Dysarthria , Hypotonia are not present . 

No signs of meningeal irritation. 

PROVISIONAL DIAGNOSIS

Heart failure with pulmonary edema

INVESTIGATIONS:

Hemogram:  

Hb: 9.5gm/dl  ( 13-17)

Mcv : 80.8fl  (83-101)

Mch: 26.5pg  (27-32) 

Rbc count : 3.59millions/cumm (4.5-5.5)

Total count 9000 cells/cu mm

Neutrophils 74

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

RFT:

Urea : 56mg/dl (12-42)

Creatinine : 6.8mg/dl (0.9-1.3)

LFT: 

Total Bilirubin - 0.9 mg/dl

Direct Bilirubin - 0.1 mg/dl

Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 220IU/l(53-128)

AST - 40 u/l

ALT - 81 u/l

Protein Total - 6.8g/dl

Albumin - 3.23 g/dl(3.5-5.5)

Globulin - 2.6 g/dl

Albumin:Globulin Ratio - 1.6

Serum iron: 60micrograms/dl .

ECG

2D echo

Right atrium dilated 

Left atrium dilated 

Left ventricle  dilated,concentric left ventricular hypertrophy ,no regional wall motion abnormality 

Ejection fraction 66%

CHEST X RAY

Final Diagnosis: Acute LVF with  pulmonary edema

Chronic kidney disease 

Anemia of chronic disease. 

TREATMENT:

Bed rest .

Fluid restriction <1.5 lit/day

Salt restriction < 2gm/day

Inj.Lasix 40mg IV/BD.

Inj.Z0FER 4mg IV/OD.

Inj.pan 40mg IV/OD.

Moniter vitals.