38 YR OLD WITH SHORTNESS OF BREATH AND PEDAL EDEMA

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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