1801006120-Short 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.

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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.

Chief complaints:-

A 42 year old male patient was brought to casuality with chief complaints of both lower limb swelling since 15 days and SOB since 2 days.

History of presenting illness:-
Patient was apparently  asymptomatic 15 
days back  & then he noticed  bilateral 
lower limb swelling which was insidious in 
onset gradually progressing pitting type extending  up to the knees.

Patient also complaining of breathlessness 
since 2 days which is Grade 2 initially 
progressed to Grade 3-4 associated with 
orthopnea & paroxysmal nocturnal dyspnoea

No h/o cough, chest pain 
No h/o pain abdomen, vomiting, loose stools
No h/o decreased urine output/ burning micturition.

No h/o palpitations

No h/o wheeze and hemoptysis

No history of abdominal distension

Past history:-

  He had history of fever, decreased appetite,  cough for which he went to a local hospital where he was diagnosed with Tuberculosis and took medicines irregularly
He was not known case of  hypertension,epilepsy,asthma

Personal history:-
Diet – Mixed 
Appetite – Decreased 
Sleep – adequate
Bladder & Bowel movements – 
Regular 
He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day.

Family history:-no relevant family history 

Treatment history:-

He was on anti tubercular therapy which he used irregularly

General examination:-
Patient is conscious,coherent,cooperative
thin built & 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:-

Cvs examination:-

Inspection:-

Chest is barrel shaped, bilaterally 

symmetrical.
Trachea is central 

Movements are equal bilaterally

JJvp-raised

 

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

Auscultation:-

S1 S2 heard
No murmurs

RRespiratory 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 

>Transverse diameter of chest

Apex beat felt in 6th intercostal 

space lateral to midclavicular line

Vocal fremitus decreased in 

right infraaxillary and 

infrascapular area.

Percussion

Dull note heard in right 

infraaxillary & infrascapular area

Resonant note heard in all other 

areas bilaterally

 Auscultation:-

Bilateral air entry present – 

Normal vesicular breath sounds 

heard

Breath sounds decreased in right 

infraaxillary and infrascapular

Vocal resonance decreased in 

right infraaxillary& infrascapular 

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:-

Higher motor functions-intact

Speech – Normal

No Signs of Meningeal 

irritation

Motor and sensory system – 

Normal

Reflexes – Normal

Cranial Nerves – Intact

Gait – Normal

Cerebellum – Normal 

Provisional diagnosis:-Heart 

failure;Right sided pleural 

effusion;chronic obstructive 

pulmonary disease.

 

Serum creatinine:-

1.1 mg/dl  ( normal 

0.9-1.3)

Blood urea - 81 mg/dl 

Hemoglobin - 11.3 

mg/dl

Chest Xray

ECG

Ultrasound findings -

Right sided pleural effusion 

with mild ascites

2D echo:-

Final diagnosis:-

Heart failure 

B/l PLEURAL 

EFFUSION (R > L)

   Copd 

Treatment : 

-Fluid 

restriction<1lit/day

-Salt restriction 

<2gm/day

-Tab.Lasix 40mg twice 

daily

-Tab.Met-xl 25mg Bd

-Blood pressure,pulse 

rate,temperature and spo2 

monitoring