1801006085 - LONG CASE

 

This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

This E blog also reflects my patient-centered online learning portfolio and your valuable input in 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

               CASE REPORT 

48 years old male who was a daily wage labourer by occupation, resident of  was brought to medicine opd with chief complaints;

Shortness of breath since 5 days 

Decreased urinary output since 5 days

Swelling of both the lower limbs since since a year (on and off)

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 year back then he developed bilateral pedal edema which was on and off in nature(since 1 yr)  and was present from ankle to knee region , pitting type.

For this he visited a hospital and there he was on conservative management. He was diagnosed with hypertension and started on medication (Tab. Telmisartan 40mg OD since 1yr).

On the sunday (12/3/23)night around 12am he had an episode of shortness of breath of class 4(NYHA)which was sudden in onset and gradually progressive , associated with Paroxysmal nocturnal Dyspnea and orthopnea.

During his stay in hospital he has undergone dialysis 3 times.

No history of chest pain , sweating, palpitations.

Urine output is decreased, narrow streamlined urine.

No history of burning micturition, fever.

No history of cough

DAILY ROUTINE :

He wakes up around 5 am in the morning and does his household chores , goes to work for 5 to 6 hrs and returns back home around lunch time 1pm and take rest for the day. He will have his dinner around 7 30 pm and goes to sleep at 9 pm. He now has stopped his daily work since a year.

PAST HISTORY :

Known case of hypertension 

Not a known case of diabetes, asthma , epilepsy, Tuberculosis , CAD.

No Similar complaints in the past.

FAMILY HISTORY :

No significant family history 

DRUG HISTORY :

History of NSAIDS Abuse since 4years.

PERSONAL HISTORY :

Appetite - Normal

Diet - Mixed

Sleep - adequate 

Bowel habits - regular 

Bladder habits - decreased 

Addictions - history of smoking (beedi 4 per day so 6 pack years), history of alcohol consumption (since 25 yrs occasionally whisky 90 ml each time).

GENERAL EXAMINATION :

(Consent was taken)

Patient is conscious, coherent and cooperative.

Moderately built and moderately nourished.

Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing- absent 

Lymphadenopathy- absent 

Edema - bilateral lower limb edema , pitting type , seen beyond ankle region.

VITALS :

Temperature - Afebrile (98.6F)

Pulse rate - 78 bpm

Blood pressure - 130/80 mm Hg

Respiratory rate - 17 cycles per minute 

SpO2 - 95%

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSYTEM:

INSPECTION :

No rise in JVP

No Precordial bulge

No visible pulsations

PALPATION :

Apical impulse - Diffuse (Shifted down and outwards)

No Parasternal heave / thrills

AUSCULTATION :

Apex beat - 6th intercostal space anterior axillary line

S1 , S2 heard 

RESPIRATORY SYSTEM:

INSPECTION :

Trachea - midline

Shape of chest - elliptical 

Chest is bilaterally symmetrical 

Bilateral airway entry Present

No chest wall defects

Presence of a healing, crusted ulcer on the right hemithorax medial to nipple.

No sinuses / scars

PALPATION :

Trachea - midline

Chest expansion - symmetrical 

Chest circumference - 34 cms

No Tenderness over the chest

PERCUSSION:

                                Right       Left

Supraclavicular     R              R

Infraclavicular       R              R

Mammary               R              R

Inframammary      R              R

Axillary                    R              R

Infra axillary           R              R

Supra scapular       R               R

Infra scapular         R               R

Inter scapular         R               R

(R - resonant)

AUSCULTATION:

                                                Left        Right

Supraclavicular  Nvbs.      Nvbs

Infraclavicular    Nvbs.      Nvbs

Mammary           Nvbs.       Nvbs

Inframmamry    Wheeze.   Nvbs

Axillary                Nvbs.        Nvbs

Infraaxillary        Wheeze.    Nvbs

Suprascapular    Nvbs.        Nvbs

Infrascapular      Nvbs.        Nvbs

Interscapular    Nvbs.         Nvbs

(Nvbs - Normal vesicular breath sounds )

ABDOMINAL EXAMINATION

Inspection:

Shape - scaphoid

No scars / sinuses 

No visible dilated veins

Palpation:

No tenderness 

No palpable masses

Auscultation:

Bowel sounds heard

CENTRAL NERVOUS SYSTEM EXAMINATION:

Speech - normal

No focal neurological deficits 

Cranial nerves examination-normal

Motor examination-

     Bulk - Normal  

     Normal tone

     Power 5/5 in both upper and lower limbs

     Reflexes - intact

Sensory examination - Normal findings.

PROVISIONAL DIAGNOSIS :

Left Heart failure (with preserved ejection fraction) with chronic kidney disease (secondary to NSAID abuse)and with hypertension.

INVESTIGATIONS:

Hemoglobin - 7.7 gm/dl

Total count - 14,100 cells/cumm

Lymphocytes - 16%

PCV - 23.1 vol%

SMEAR :

  RBC - Normocytic normochromic

  WBC - increased count (neutrophilic leucocytosis)

  Platelets - adequate

Serum creatinine - 4.0 mg/dl

Blood urea - 95mg/dl

ABG :

  PH 7.43

  Pco2 - 31.6 mmHg

  Po2 - 64.0 mmHg

  HCO3 - 21.1 mmol/l

Urine examination :

  albumin ++

  sugar nil

  pus cells 2-3

  epithelial cells 2-3

  Red blood cells 4-5

Random blood sugar - 124 mg/dl

CHEST X RAY :

Electrocardiogram :

2D echocardiogram:

https://youtu.be/PXyN0A2G1bM

Dialysis :

 TREATMENT :

Ryle’s feed : 100 ml milk with 2             scoops protein powder 4th hourly and 100 ml water 6th hourly.

Inj. Thiamine 100mg in 50 ml NS TID

Inj. Piptaz 2.25g IV TID

Inj. LASIX 40mg IV BD

Inj. Erythropoietin 4000IU SC Once weekly

Inj. PAN 40 mg IV OD

Tab. Nicardia Retard 10mg RT BD

Tab. Metoprolol 12.5mg RT OD

Tab. Orofer RT OD

Cap. BIO D3 RT OD

Hemodialysis

Nebulisation with Duolin 8th hourly and Budecort 12th hourly 

Intermittent CPAP

Allow sips of oral fluid 

Monitor vitals.