60 YEAR OLD MALE PRESENTED WITH SHORTNESS OF BREATH AND PEDAL EDEMA

 

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 centred 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 and treatment plan. 

A 60 year old male patient, resident of kakirani (yadadhri district) presented to the OPD with the chief complaints of 

• Swelling of lower limbs since 4 days. 
• Shortness of breath since 4 days. 
• Decreased urine output since 4 days. 

History of presenting illness

The patient was apparently asymptomatic 5 years back when he had episodes of giddiness and had fatigue for which he went to hospital. He was diagnosed with hypertension and was prescribed medication.  He takes his medication regularly and goes of check up every three months. 

3 years back he started experiencing shortness of breath (grade 2: he has to stop for breath when walking at own pace.) due to which he stopped farming and started staying at home since then. 

1 year back, the shortness of breath progressed to grade 3 and he also had complaints of swelling of lower limbs. For these he went to a hospital in Hyderabad where he underwent dialysis. He was referred to our hospital for another session of dialysis after 10 days from then.  After which his symptoms were relived but the SOB was still of grade 2. He was prescribed medication.  

The patient complains of swelling of lower limbs and face since 4 days  It was initially till the ankle later it progressed till the knee in 2 days. 

He also complains of increase in severity of shortness of breath. It was previously of grade 2 now has progressed to grade 3 (sob on walking 100m or doing daily work). He has orthopnea.

 He also complains of decreased urine output since 4 days. He had no burning micturition. 

The patient complains of cough since 3 years. It was productive  since 5 days. The sputum is white in colour, scanty, non foul smelling and non blood tinged. 

No history of fever, palpitations, chest pain, PND, wheeze.

PAST HISTORY 

he is not a known case of DM, bronchial Asthama, epilepsy, Coronary vascular diseases. 

PERSONAL HISTORY

Appetite: normal 

 diet: mixed

Bowel movements: regular

Bladder: decreased urine output since 4 days 

Sleep: disturbed since 2 days due to increase in cough during night 

Allergies: none 

Alcohol consumption: he consumes alcohol during festivals (90ml) but has stopped since 3 years. 

GENERAL EXAMINATION:

The  patient is conscious, coherent, cooperative.

He is moderately built and moderately nourished. 

Edema of the lower limbs was noticed.  It was pitting in nature 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy. 

Vitals:

Temp-98.4 degrees F

BP-130/70mm hg

PR- 73bpm

RR-18cpm

Respiratory system examination: 

Bilateral air entry was present. Crepts were noticed in all areas. 

On percussion dullness was noticed in left and right infra-scapular areas 

Decreased breath sounds were heard in the left and right infrascapular areas and left infra-axillary area. 

CVS: 

Apex beat was localised in the 4th intercostal space 1 cm medial to mid clavicular line. 

S1 and S2 are heard. 

No abnormal heart sounds were heard 

JVP was raised. 

CNS:

No fuctional deficits were noticed. 

Per abdominal examination: 

Abdomen is tense. Skin of the abdomen seems thickened 

Shifting dullness is noticed. 

No organomegaly was noticed.