1801006108- SHORT CASE

 

 This is an 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 patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

 

A 50 year old male came to opd with the 

CHIEF COMPLAINTS:

 

•   shortness of breath since 13 days  
• Swelling of lower limbs since  9 days .

• Decreased urine output since 9 days

 HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 13 days ago then he developed 

-Shortness of breath which was insidious in onset and progressed to Grade 4 ,aggrevated on lying down and  walking and relieved on taking rest.

- He also developed bilateral pedal edema ,since 9 days which is pitting in nature which is insidious in onset and it is initially Grade 1 and presently progressed  upto Grade2 extending till mid thighs

-He also had decreased urine output since 9 days.

No history of chest pain,palpitations,syncope

no history of fever, cough, burning micturition

PAST HISTORY: 

•    History of fall from tree 3 years ago
  

•   Diagnosed with Tuberculosis and Diabetes mellitus 3 years ago 

•   Noticed swelling in both legs and on consultation was diagnosed with Chronic kidney disease 1 year ago.
  

• Not a known case of  Hypertension, thyroid, Asthma, epilepsy in the past
  
•  No history of any surgeries in the past.
• diagnosed with hypertension when he came to the hospital,no prior use of anti hypertensive drugs.
  

TREATMENT HISTORY:

Drug history:

•  NSAIDS intermittently to relieve neck pain

•  Antitubercular therapy 3 years ago

 

• Metformin 500mg three times a day

PERSONAL HISTORY:- 

Diet - mixed 

Appetite-decreased

Sleep - adequate 

Bowel - regular; 

Micturition : decreased urinary output since 9 days 

Addictions - occasionally alcohol consumption 

 Cigarette stopped 25 years back before 1 pack per year.

Daily routine:

He is farmer by occupation and used to go to work by waking up at 6 am and breakfast at 7 am ,completes agriculture/field work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm

consumes non vegetarian diet weekly once for lunch

He stayed at home since the fall from tree due to low backache            since last 3 years

FAMILY HISTORY:- 

no significant family history 

 

ALLERGIC HISTORY:- 

no allergies to any kind of drugs or food items

GENERAL EXAMINATION:- 

Patient is conscious, coherent, and cooperative 

Moderately built and well nourished 

No pallor 

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

 Pitting edema seen in both lower limbs extending till mid thigh areas

VITALS:

Temperature - Afebrile

Pulse Rate - 102 bpm

Respiratory Rate - 15cpm

Blood Pressure - 150/90mmg

Sp02 - 97% at Room air

GRBS - 203 mg/dl

 

 

 

 

CVS EXAMINATION :

INSPECTION:

• shape of chest is normal
• jugular venous pulse is seen
• no precordial bulge is seen

• apical impulse is not well appreciated 

PALPATION:

• Apex beat is shifted to 6th intercoastal space 
• no parasternal heaves 
• no thrills 
• no dilated veins

PERCUSSION:

• left heart border is not confined to normal limits
• right heart border is with in confined limits

AUSCULTATION:

• mitral area, tricuspid area, pulmonary area, aortic area - S1,S2 heard 

• no additional sounds are heard 

RESPIRATORY SYSTEM:

INSPECTION:

Bilateral Air entry Present

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

PALPATION:

Trachea - Midline

Chest is bilaterally symmetrical and elliptical 

Percussion                     Right                   Left
Supra clavicular:        resonant         resonant   
Infra clavicular:          resonant         resonant 
Mammary:                  resonant                 dull
Axillary:                      resonant               dull
Infra axillary:             resonant                 dull
Supra scapular:         resonant            resonant
Infra scapular:           resonant                dull
Inter scapular:           resonant                   dull   


Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:                 NVBS         decreased 
Axillary:                     NVBS         decreased 
Infra axillary:             NVBS        decreased 
Supra scapular:          NVBS                NVBS
Infra scapular:           NVBS        decreased 
Inter scapular:           NVBS        decreased 

 

PERABDOMEN:

 

INSPECTION

Abdomen is Mildly distended

Umbilicus is central in position

A visible scar due to injury due to a fall around the umbilicus.


PALPATION -

No Tenderness on superficial palpation.

 

No local rise in temperature

Liver is Non Tender and not palpable

Spleen is Not palpable

PERCUSSION:Fluid thrill absent

AUSCULTATION- Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM EXAMINATION: 

 
 HIGHER MENTAL FUNCTIONS: 

• Conscious 

•  Well Orientation to time, place and person

• Speech and language – normal

 

• Memory – immediate-retention and recall, recent and remote are present 
• No delusions, hallucinations 
• No Emotional lability

2.CRANIAL NERVES -        left                        Right               
                                              Normal           normal        
3.MOTOR SYSTEM-

      Bulk
 Inspection                                normal     normal
 Palpation                                normal       normal            
Measurement

Upper limb – 10cm below acromion  ( same on both )
Lower limb 18 cm below tibial tubercle  (same on both)

Tone

Upperlimb                                           Normal         Normal
Lowerlimb                                           Normal        Normal

Power

a. Neck muscles                                Good             Good

b. Upper limbs     
                    
i) Shoulder                                           5/5                5/5
Flexion-Extension                           
Lateral Rotation-Medial Rotation     5/5                5/5
Abduction -Adduction                        5/5                 5/5
ii) Elbow
Flexion-Extension                               5/5                5/5
iii) Wrist
Dorsi flexion-Palmar flexion              5/5                5/5
Abduction-Adduction                         5/5                 5/5
Pronation-Supination                         5/5                 5/5
iv) small muscles of hand               Good              Good
v) Hand grip                                      Good              Good


c. Lower limbs
i) Hip                                                     5/5                5/5
Flexion-Extension
Abduction-Adduction                          5/5                5/5
Lateral Rotation-Medial Rotation       5/5                5/5


ii) Knee
Flexion-Extension                                 5/5                5/5
iii) Ankle
Dorsi flexion-Plantar flexion                5/5               5/5
Inversion-Eversion                                5/5               5/5
iv) Small muscles of foot                   Good           Good



REFLEXES

SUPERFICIAL REFLEXES
A.Corneal reflex                                 Present
B.Conjunctival reflex                         Present    
C.Abdominal reflex                           Present     
D.Plantar reflex                                  Present    

DEEP REFLEXES
A.Biceps                          +2            +2                   
B.Triceps
                                          +2            +2    
C.Supinator    
                                   +2                  +2
D.Knee jerk   
                                     +2                  +2
E.Ankle jerk  
                                     +2                  +2

SENSORY SYSTEM - Normal
CEREBELLAR SIGNS-  Absent     

SIGNS OF MENINGEAL IRRITATION 

• neck rigidity absent
• kernigs sign negative 

• brudzinski sign negative  

 

PROVISIONAL DIAGNOSIS :Heart failure Renal failure 

 

INVESTIGATIONS: 

 

Complete blood picture

 

Hemoglobin 11.7 gm/dl

Total count    9,000 cells/cumm

Neutrophils. 74

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

Pcv. 36.5 vol

Mcv. 82.8 fl

RDW- CV 19.1 %

RBC COUNT:. 4.4 million/cu/mm





LIVER FUNCTION TEST

Total Bilirubin - 0.9 mg/dl
Direct Bilirubin - 0.1 mg/dl
Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 221 u/l
AST - 40 u/l
ALT - 81 u/l

Protein Total - 6.8g/dl
Albumin - 4.2 g/dl
Globulin - 2.6 g/dl
Albumin:Globulin Ratio - 1.6

Renal Function Test

Urea - 64
Creatinine - 4.3
Na+   - 138
K+      - 3.4
Cl-       - 104

Fasting Blood Sugar - 93mg/dl
PLBS - 152 mg/dl

HbA1c  - 6.5%

ABG :
pH : 7.3
pCO2 - 28.0
pO2 - 77.4
HCO3-.13.5
Spo2-94.7

2D ECHO:

Aortic Valve - Sclerotic

Moderate MR +, Moderate TR+ with PAH

Global Hypokinetic , No AS/MS

Moderate LV Dysfunction+

Diastolic Dysfunction presentReduced ejection fraction 

 

 
USG CHEST:

Free fluid noted in bilateral pleural spaces (left more than right)

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH reduced  EJECTION FRACTION

 

BILATERAL PLEURAL EFFUSION

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

 

TREATMENT:

• rest is advised
  

• Fluid Restriction less than 1.5 Lit/day

•  Salt restriction less than 1.2gm/day

• INJ. Lasix 40mg IV / BD

• TAB MET XL 25 mg

•  TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

•  INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

• INJ. PAN 40 MG IV/OD

• INJ. ZOFER 4 MG IV/SOS

•  Strict I/O Charting

•  Vitals Monitoring

•  TAB. ECOSPRIN AV 75/10 MG PO/