A 55 Yr old man presented with shortness of breath 20 days and swelling of both lower limbs since 10 days



 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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



A 55 Yr old male presented with shortness of breath 20 days back and swelling of both lower limbs since 10 days

History of presenting illness :

Patient was apparently asymptomatic 2 years back then he developed Shortness of breath while lifting weights  then 20days back started to develop SOB even while doing normal work and occasionally it used to present while taking rest or on lying down , walking  and relieved to some extent in sitting position. 

Patient also complains of Pedal Edema from 10 days back which is insidious in onset gradually  progressed till knees 

History of facial puffiness 1 week back and it is resolved .

history of  backache for the past 5years  which was non radiating ,non progressive relived with rest and started to take NSAID medication every 2-3 days for the past 3years .

No history of chest pain , palpitations , sweating 
No history of fever , cold , cough 
No history of burning Micturition , frothy urine , Hematuria 
No history of decreased urine output 

History of past illness :

Not a known case of Diabetes Mellitus , Hypertension , Asthma , TB , CAD , CVA , Epilepsy 

Underwent surgeries for hernia right side 8 years back and hernia left side 4 years back . 

Personal History : 

Patient takes mixed diet , appetite is good , bowel and bladder movements are regular , sleep is disturbed .

He consumes 90 mL whiskey daily from past 10 years and chewing gutka for the past 15 years







Daily routine : 

Patient wakes up around 6 in the morning and goes out around 7 and has his breakfast around 10 am , continues to work and around 2 am he comes home and sleep for an hour or 2 and resumes his work in vegetable Market till 9 pm . Later he drinks 90 mL whiskey and comes home , have dinner and sleep around 10 pm .

Family history : 

His mother and elder brother had similar complaints of Shortness of breath .

Treatment history : 

Patient used NSAIDS for back pain every 2-3 days for past 3 years . 

GENERAL EXAMINATION 

Patient is examined in well lit area After taking consent 

Patient is conscious , coherent , cooperative , well oriented to time , place , person . 

Patient is moderately built and moderately nourished . 


Pallor - present 

Icterus - absent 
Cyanosis - absent 

Clubbing - present







No generalised lymphadenopathy 

Pedal edema - Grade ll ( Till knees )
                        Pitting type

VITALS : 

Temp - Afebrile 
BP - 130/70 mm Hg
PR - 66 bpm
RR - 18cpm
GRBS - 92 mg/dL
Elevated JVP

CVS EXAMINATION : 

INSPECTION

chest normal in shape
no visible pulsations
no scars 
no dilated veins

PALPATION

No thrills , heaves


AUSCULTATION 

Done in all 4 areas . S1 S2 heard . No murmurs heard 

Apex beat - 6th ICS , 2 cms lateral to Mid clavicular line


RESPIRATORY SYSYTEM-

INSPECTION- 

trachea appears central

chest wall normal

no scars

no sinuses 

no dilated veins 

PALPATION

 trachea central 

symmetrical expansion of chest seen

Tactile vocal fremitus -decreased  on right mammary and axillary area

PERCUSSION 

dullness felt at axillary area on right side

AUSCULTATION

normal vesicular breath sounds heard and diminished sounds at right mammary and axillary areas,

CNS - no focal neurological deficits elicited

PER ABDOMEN  - soft , non tender , no hepatomegaly , spleen not palpable 


PROVISIONAL DIAGNOSIS 

Heart failure with reduced ejection fraction , with right sided pleural effusion.

INVESTIGATIONS

X ray



Obliteration of right sided costophrenic angle
Enlarged cardiac silhouette 


LFT





Blood urea





Complete urine examination


Serum creatinine





Hemogram






Usg report 






Colour Doppler 






ECG





Treatment- 

1.inj lasix 40 mg  iv bd

2.fluid restriction <1lt/day and salt restriction <2gm/day.

3.tab.ecosprin po

4. Tab MET-XL 12.5 mg po

5. Inj. Thiamine 200mg direct iv bd

6. Pantop 40 mg po bd

7. Bp charting every 4th hrly and  grbs 12th hrly



Comments

Post a Comment

Popular posts from this blog

38 year old male with liver abscess

Image
    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.   HISTORY OF PRESENT ILLNESS: He was apparently asymptomatic 12 days back and then he developed fever which is sudden in onset gradually progressive continuous type associated with chills and rigor; no aggravating and relieving factors; not associated with diurnal variation and evening rise of temperature. H/o abdominal pain since 12 days which is sudden in onset gradually progressive non radiating and diffuse type aggravated by taking deep breaths and relieved on taking rest. No h/o of nausea, vomiting, loose stools, loss of appetite, weight loss, burning micturition, de
Read more

54 Y/M with vomitings, SOB, fever

Image
This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 Patient came to causality with complaints of Fever since 5 days SOB since 5 days Vomiting for 3 days The patient was apparently asymptomatic 5 days back then he developed fever, high grade, not relieved with medication , associated with chills and rigors. SOB since 5 days, grade III , no orthopnea , pnd. Also presents with vomitings since 3 days, non bilious, non blood stained , watery, 2-3 episodes. Ulcer over left foot,since 4 months, associated with edema of foot,  H/o abscess drai
Read more

57 yr old male with cervical and lumbar spondylosis and acute ishaemic stroke and with respiratory distress

Image
  57 yr old male with cervical and lumbar spondylosis and acute ishaemic stroke and with respiratory distress on  June 15, 2023 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT A 57 yr old male resident of Nalgonda security guard in a bank in Nalgonda came with chief complaints of fever since 1month and altered sensorium 1 month back and shortness of breath since 6days HISTORY OF PRESENT ILLNESS : He is apparently asymptomatic before 5yrs then he developed neck pain and backache which are insidious in onset gradually progressive dragging type associated with muscle spasms and clicking, popping sensation in the neck and shock like pain on the back and not a
Read more