38 YR OLD WITH SHORTNESS OF BREATH AND PEDAL EDEMA

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 come up with a diagnosis and treatment

Chief complaints::

A 38 yr old chef by occupation came to casuality with
Shortness of breath since 1 month
Pedal edema since 1month
Decreased urine output since 1month

History of present illness:::

Patient was apparently asymptomatic 1month back then he developed shortness of breath 
SHORTNESS OF BREATH which was insidious in onset gradually progressive
Grade 2-3 according to MMRC  associated with orthopnea , no paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,no aggrevating or relieving factors

Pedal edema was insidious in onset gradually progressive pitting type  from ankle to shin of tibia associated with decreased urine output and facial puffiness 
H/o fever -low grade ,intermittent ,no chills and rigor,associated with burning micturition
No nausea,vomiting,loose stools
H/o cough since child hood (k/c/o bronchial asthma) cough was productive with sputum scanty whitish yellow ,no blood tinged,no foul smelling,no postural or diurnal variation 


Past History:

-K/c/o Bronchial asthma since childhood
-H/o herniotomy 7yrs back
-H/o sob after herniotomy was managed symptomatically
-H/o chest pain 1yr back and he diagnosed as bronchectasis under acute infective exacerbation with respiratory failure on o2 support  with cor pulmonale with Mod
-For which Home oxygen used at 2lt/min via nasal prongs
-H/o pulmonary Tuberculosis in childhood 
-Not a k/c/o HTN,DM,epilepsy,CAD,Thyrood disorders

Family history::
 Not significant
Personal history::
 
Diet:mixed
Sleep ::  not adequate
Appetite:: decreased
Bowel and bladder:: irregular
Addictions::no addictions
General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

No pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
Edema present -pitting type


Vitals

Temperature::98.3f
PR-88bpm
Bp-100/70 mmhg
RR--18cpm

Local examination::







Respiratory system::
Inspection::

B/L symmetrical 
Trachea appears to be central
Supraclavicular and infraclavicular hallowing absent
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles absent
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 6th ICS in mid clavicular line

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::

                                             RT.           LT .

Supraclavicular.         Resonant.    Resonant
Infraclavicular.           Resonant.     Resonanat
Mammary.                  Resonant.     Dullness
Axillary                        Resonant.      Resonant
Infraaxillary.                Resonant       Resonant
Suprascapular.           Resonant.      Resonant
Interscapular.             Resonant       Resonant
Infrascapular.             Resonant        Resonant

Auscultation::

 B/L air entry present
 On auscultation:: Diffuse Crepts are heard (more prominent over bilateral infra clavicular, infrascapular,suprascapular,infra axillary ,mammary area )


PER ABDOMEN::
Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
No Tenderness present
No palpable mass 
No free fluid
Liver not palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard:

Cardio vascular system:
Jvp -Raised
Apex beat felt in 6th ICS in mid clavicular line
S1s2 heard
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Chest xray PA view::on 22/6/23
23/6/23
24/6/23

25/623
26/6/23


ECG::



Hemogram::
On 23/6/23

 Hemoglobin.14.3gm%
Total leucocyte count 14000
Neutrophils 89.7%
Lymphocytes 5.7%
Monocytes 4.6%
Eosinophils 0%
Basophils 0%
Platelet count 73000

Mcv-72
Mch-20
Mchc-28

Rbs-135mg/dl

Complete urine examination::
pale yellow urine
Clear
Rbcs nil
Casts nil
Pus cells-2-3
Epithelial cells 2-3


Liver function tests::on 22/06/23

Total bilirubin:2.4mg/dl
Direct bilirubin:0.35mg/dl
ALP:115 U /L
SGOT:182U /L
SGPT :156 U /L
TotalProteins:7.0g/dl
Albumin-3.1g/dl
Albumin/GlobulinRatio:0.82

RFT
serum creatinine::2.5mg/dl
Uric acid -8.9mg/dl
Urea-38
Phosporus-5.1
Na+::144 mEq/L
K+::3.2mEq/L
Cl-::102mEq/K
 calcium::10.1


Serology-
HBSAGRAPID-NEGATIVE
HIV1/2RAPID-NON REACTIVE
ANTI HCV ANTIBODIES- Negative

Usg abdomen on 22/06/23
No sonological abnormalities detected
 2d echo


 Investigations 25/6/23 and 26/6/23

Hrct report




                        





Provisional diagnosis::HEART FAILURE (CORPULMONALE) with TYPE 2 RESPIRATORY FAILURE secondary to ?bronchial Asthma  with Acute kidney injury  secondary to UTI/ATN (MODS)

Treatment::
1.fluid restriction
2.head end elevation
3.o2support to maintain saturation
4.chest physiotherapist
5. Nebulisation budecort





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