Monday, June 13, 2022

LONG CASE- A 35 year old with shortness of breath and palpitations


Hall ticket no. 1701006183






 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 35 year old male patient, bartender by occupation and a resident of sathepally presented to the OPD with the chief complaints of 

  1. Shortness of breath since 1 month
  2. Palpitations since 7 days 
  3. Pedal oedema since 2 days 
  4. Cough since 2 days. 



HISTORY OF PRESENTING ILLNESS


The patient was apparently asymptomatic 1 month back when he started having shortness of breath which was initially of grade 2 (NYHA classification) - slight limitation of activity -ordinary activity results in fatigue. Which aggravated to grade 3 (marked limitation of physical activity- less than ordinary activity causes dyspnea) 10 days ago.  


It later progressed to grade 4 (dyspnea at rest) 

7 days ago.

The shortness of breath was aggravated on lying down and was relieved on sitting upright 


The shortness of breath was associated with palpitations since 7 days. 

He gives history of paroxysmal nocturnal dyspnea. During these episodes, once he wakes up he voluntarily stops himself from going back to sleep. 


He also complains of pedal edema since 2 days. It was of pitting type and it was up to the level of his ankle joint. 

There were no aggravating or relieving factors as such. 


The patient developed cough 2 days back. It is not associated with sputum. 


He doesn’t have any complains of excessive sweating, chest pain, chest tightness, fever, decreased urinary output. 


He gives a history of alcohol binge 8 days ago.  


PAST HISTORY: 

There are no similar complaints in the past. 

He is not a known case of diabetes mellitus, hypertension, epilepsy, bronchial Asthma. 


PERSONAL HISTORY 

Diet - Mixed

Appetite - Normal

Bowel and Bladder- Regular.

Sleep - Disturbed

No known drug/food allergies 

Addictions: he has consumed alcohol everyday since the age of 20 (15years). He drinks 90-180ml of brandy everyday. 

He is exposed to smoke as he works in a bar 


FAMILY HISTORY 

Insignificant 


GENERAL EXAMINATION 


Patient was examined after a well informed consent in a well lit room 

The patient is conscious, coherent and cooperative and well oriented to time place and person. 

He is Moderately built and nourished. 

There are no signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy 

He had pedal Edema upto his ankle joint. It was of pitting type. 

Truncal obesity is seen. 




VITALS:


Temperature: 98.6°F 

Respiratory rate: 18 cycles per minute 

Pulse rate : 160 beats per minute 

Blood pressure : 110/80 mm of Hg 


SYSTEMIC EXAMINATION:


CARDIO VASCULAR SYSTEM:




Inspection:

There are no  chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 


Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 


Auscultation

S1 and S2 were heard 

There were no added sounds / murmurs. 


RESPIRATORY SYSTEM EXAMINATION

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 


CNS EXAMINATION

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


ABDOMINAL EXAMINATION:

There is no local raise of temperature. 

No tenderness 

The abdomen is soft

No organomegaly. 

No scars, sinuses, fistulas and engorged veins 



INVESTIGATIONS


Complete blood picture :

Hemoglobin - 12 gm%

TLC - 14,900 cells/cu.mm

 (Neutrophils- 89%)

PCV - 37.9%

RDW - 16.9%

MCV -70.9fl

MCH - 22.4pg

Platelet count - 2.84 lakhs/cu.mm

RBC - 5.36 million/cu.mm


Liver function tests

Total bilirubin - 2.32 mg/dl

Direct bilirubin - 0.02 mg/dl

SGPT - 58 IU/L

SGOT - 34 IU/L

ALP - 93 IU/L

Total protein- 6.9 g/dl

Albumin - 4.2 g/dl

Albumin / Globulin ratio - 1.5


Complete Urine Examination: Normal 


Serum creatinine: 1mg/dL 

Blood urea: 22mg/dL


Troponin I - 22.5ng/dL



ECG













2D ECHO: 


Report: moderate LV dysfunction (EF- 38%) 
              All chambers are dilated 
              No LV clots


X-ray 




PROVISIONAL  DIAGNOSIS:

Heart failure with dilated cardiomyopathy and atrial fibrillation 


Treatment


Tab. DILTIAZAM - 30mg PO BD


Tab. CORDARONE - PO BD


Inj. LASIX - 40mg IV TID 


Tab. ECOSPRIN - 150mg PO OD


Inj. CLEXANE - 60mg SC OD


Tab. CLOPITAB - 75mg PO OD.


Tab ATORVA - 50mg PO OD


Tab. AUGMENTIN - 65mg PO BD


Tab. AZITHROMYCIN - 500mg PO BD


Inj. THIAMINE - 20mg IV TID




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