A 52 year old male with Shortness of breath

 Note : This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' 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 of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. 

I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

Name : M.Aishwarya

Roll No : 89

Case Scenario : A 52 year old male who is a vegetable vendor by profession, came with complaints of :

• Shortness of breath - since 25 days
• Swelling in the legs, face and neck - since 25 days

History of Present Illness :

• Patient was apparently asymptomatic 8 years ago, then he developed back pain, non radiating and non progressive, uses some pain killers for relief until recently
• Patient started experiencing shortness of breath of grade - 3,bsince 2 years, but exacerbated to grade - 4 since past 25 days. Orthopnea - present, relieved on sitting upright.
• Pedal edema was observed first in the left leg, then right leg since 1 year, gradual progression to bilateral and swelling in face and neck also seen since 25 days, gradually progressive.
• Patient had an episode of syncope 2 months ago, sudden onset.
• No H/O fatigue, chest pain, palpitations, cough, sore throat, fever, cyanosis, hemoptysis, joint pains.

Past History :

• Not a known case of hypertension, DM, epilepsy, asthma, COPD, CAD, past blood transfusions
• Hernia operation in right leg about 12 years ago and left leg about 8 years ago.

Personal History :

• Diet - Mixed
• Appetite - reduced
• Sleep - disturbed
• Bowel movements - constipation
• Micturition - Normal, no H/O burning micturition, hematuria
• Addictions - Daily intake of alcohol - 90 mL/day since past 20-30 years.
•  Chewing Khaini - 5 times/day since past 5-6   years

Family History: Not significant

GENERAL EXAMINATION

1) Pallor : Not seen 

2) Icterus : Not seen

3) Cyanosis : Not seen

4) Clubbing of fingers/toes : Not seen

5) Lymphadenopathy : Not seen

6) Oedema of feet : Seen

7) Malnutrition : Not seen

8) Dehydration : Not seen

9) Temperature : Afebrile

10) Heart rate : 60 BPM

11) Respiratory rate : 20 breaths/min

12) B.P : 150/90 mm of Hg

13) sPO2 : 98% 

SYSTEMIC EXAMINATION

(1) CVS

1. Thrills - None
2. Cardiac sounds - S1, S2  (+)
3. Cardiac murmurs - none

(2) Respiratory System

1. Dyspnoea - None
2. Wheeze - None
3. Position of trachea - Central
4. Breath sounds - Vesicular
5. Adventitious sounds - None

(3) Abdomen

1. Shape - Scaphoid
2. Tenderness - Not seen
3. Palpable masses - None
4. Hernial orifices - Normal
5. Free fluid - Not seen
6. Bruits - None
7. Liver - Not palpable
8. Spleen - not palpable
9. Bowel sounds - Normal
10. Genitals - Normal

(4) CNS

1. Level of consciousness - Conscious
2. Speech - Normal
3. Signs of meningeal irritation - None
4. Cranial Nerves, sensory system and motor system - Normal in functioning
5. Glasgow scale - 15/15
6. Reflexes :

                         Right.                              Left
Biceps.              2+.                                   2+

Triceps.             2+.                                   2+

Supinator         2+.                                   2+

Knee.                 2+.                                   2+

Ankle.                +.                                      +

7. Cerebral Signs :

1. Finger Nose coordination - Present
2. Knee-heel coordination - Present

Lab Investigations :

                                  

ECG

Color Doppler 2D ECHO

USG REPORT

Urine Analysis

Provisional Diagnosis : Heart failure with reduced ejection fraction with Bilateral pleural effusion and ?CKD 

Treatment Regime :

02/01/23

• Inj. Lasix 40 mg IV
• Fluid restriction <1 litre/day
• Salt restriction < 2 grams/day
• Tab. Ecospirin 75/20 mg
• Inj. Thiamine 100 mg IV

03/01/23

• Tab. Met.xl 12.5 mg
• Tab. Pan 40 mg
• Tab. thiamine 100 mg IV
• Tab. Ecospirin 75/20 mg
• Syr. Lactulose - 15 mL

04/01/23

• Inj. Lasix 40 mg IV
• Inj. Thiamine 200 mg IV
• Tab. Pan 40 mg
• Tab. Ecospirin 75/20 mg
• Tab. Met.xl 12.5 mg
• Syr. Lactulose 15 mL

05/01/23

• Inj.Thiamjne 200 mg IV
• Inj. Lasix 40 mg IV
• Tab. Pan 40 mg
• Tab. Ecospirin 75/20 mg
• Tab.Met.xl 12.5 mg
• Syr. Lactulose 15 mL

06/01/23

• Inj. Lasix 40 mg IV
• Tab. Ecospirin 75/20 mg