Tuesday, March 29, 2022

60 year old male with SOB and 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 man, resident of yedadri district and a palm tree climber by occupation, presented to the hospital with the chief complaints of 

  • shortness of breath since 6 months 
  • Pedal edema since 10 days 


HISTORY OF PRESENTING ILLNESS 


The patient was apparently asymptomatic 10 years back when he had an episode of dizziness for which he went to a doctor and was diagnosed with hypertension. 

The patient was prescribed medication (Cilnidipine) and he is compliant with the medication till date. 


The patient has had complaints of shortness of breath since 6 months. It was initially of class 2 NYHA classification (ordinary physical activity results in SOB) and progressed to class 3 NYHA (less than ordinary activity results in SOB). He complains of decreased urine output since 6 months. For which he went to a doctor and was prescribed furesamide. He is compliant with the medication. No other information is available with the patient regarding that visit.   


He also has orthopnea and PND. 


He has had pedal edema since 10 days which was initially till his ankle joint now involves his entire lower limb as well his upper limbs. 


He doesn’t have any complaints of palpitations, chest pain, sweating, cough, fever, burning micturition, loin pain, hematuria. 


Past history 

He was diagnosed with HTN 10 years back. 

He is not a known case of DM, HTN coronary artery diseases, Asthma, TB, epilepsy. 

No similar complaints in the past 





PERSONAL HISTORY 


  • Diet: mixed
  • Appetite: Normal
  • Bowel: normal 
  • Bladder : decreased urine output since 6 months 
  • Sleep: disturbed 
  • Addictions: he used to smoke 1 packet of biddis (15years - 50 years). He used to drink 2 bottles of toddy per day. He stopped drinking toddy when his SOB started i.e. 6 months ago. 
  • Allergies (food/drugs) : nil 


Daily routine : 

He wakes up at 6:00 everyday. He brushes his teeth and take a bath and then he has breakfast. He is done with his morning routine by 8:00am. He then takes rest and watches TV. he has lunch at 1:30pm. Following which he takes an afternoon nap. He wakes up at 4:00 and has snacks. He has dinner at 8:30 and sleeps at 9:30 after watching news. 


GENERAL EXAMINATION


Patient is conscious, coherent and co-operative; well oriented to time, person, place.


Well built and well nourished.


Pedal edema, pitting type throughout leg upto hip. Pitting type edema over his Right hand upto his shoulder. Mild pitting edema over left hand as well. 


Pallor present.


No icterus, clubbing, cyanosis, generalised lymphadenopathy.


 






VITALS:
  • PR: 92bpm
  • BP: 140/90mmHg
  • RR: 18 cpm
  • Temperature: Afebrile



CARDIOVASCULAR SYSTEM: 

On palpation,

-Apex beat was diffuse

-JVP not raised

-No precordial bulge 

-No parasternal heave

On auscultation, S1, S2 heard; no murmurs


RESPIRATORY SYSTEM


INSPECTION: 

bilaterally symmetrical

Expansion of chest: Equal on both sides

Position of trachea: Central

Supraclavicular and infraclavicular areas normal

Spinoscapular distance normal

No crowding of ribs 

No visible scars, sinuses, pulsations


PALPATION:

Inspectory findings confirmed

No tenderness, local rise of temperature

Normal expansion of chest on both sides in all areas

Chest diameter: 5:7

Position of trachea: Central

Vocal fremitus: resonant note felt


PERCUSSION:

Resonant note heard over all areas


AUSCULTATION:

crepts heard over all lung fields

Vocal resonance: resonant in all areas


PER ABDOMINAL EXAMINATION:

Soft, non-tender

No hepato-splenomegaly noted


CNS

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact


CRANIAL NERVES :Normal


SENSORY EXAMINATION

Normal sensations felt in all dermatomes


MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait


REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited




CEREBELLAR FUNCTION

Normal function


No meningeal signs were elicited






EVALUATION

Hb: 9.1gm%

Serum creatinine : 10mg/dL (0.9-1.3mg/dL)

Blood urea : 132mg/dL (12-42mg/dL)

ELECTROLYTES 

Serum sodium : 134 mEq/L (136-145 mEq/L) 

Serum potassium : 3.4 mEq/L(3.5-5.1 mEq/L)

Serum chloride : 98 mEq/L (98-107 mEq/L)

2D ECHO


USG



TREATMENT : 

Tab. LASIX 40 mg  PO TID

Tab. PAN 40mg PO OD

Tab. NODOSIS 50mg PO OD

Tab. SHELCAL PO OD

Inj. EPO 4000IU Weekly once 

Tab. NICARDIA 10mg PO OD


Discussion:


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