A 60Y/F with SOB

 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 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-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment 


CHIEF COMPLAINTS:

Shortness of breath since 1 days

Decreased urine output since 3days , anuria since morning 

Facial puffiness since 3 days 

B/l pedal edema since 1 week 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week ago the developed bilateral pedal edema insidious in onset , progressive in nature, pitting type , extending upto knee joint. Decreased urine output since 3 days less than 500 ml /day , and anuria since morning. Facial puffiness since 3 days. Shortness of breath since 1 day, sudden onset, orthopnea present . No PND, chest pain , palpitations and giddiness . No history of fever , cough, vomiting loose stools , burning micturition. K/c/o seizure disorder since 18 years , H/o seizure episode once monthly and fall after episode, even on medication with sodium valproate 300 mg PO /OD.

PAST HISTORY:

K/C/O  seizure disorder on Tab. Sodium valproate 300 mg PO/BD 
Not a K/c/o HTN/ DM/ CKD/ /TB 


PERSONAL HISTORY:
Appetite-Decreased 
Diet - Mixed
Bowel and bladder - regular 
Sleep - Decreased.

General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person 

Pallor - present
Icterus - absent 
Cyanosis - absent 
Clubbing - absent 
Lymphadenopathy- absent 
Pedal edema - pitting type extending till knee 

VITALS : Temp - 98.6 F
                PR - 92bpm
                BP - 160/60 mmhg
                RR - 36 cpm
                SPO2 - 84% onRA
                             96% on 6lit of O2
                GRBS - 102 mg/dl

Systemic examination: 

CARDIOVASCULAR SYSTEM:
Inspection:
        Shape of chest is elliptical.
        JVP raised
        No visible pulsations, scars , sinuses , engorged veins.




Palpitation:
        Diffuse Apex beat present 
        Parasternal heave present
        Epigastric pulsations present         
        Palpable A2P2

Auscultation :
        S1 and S2 heard. 

PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration 
No scars , sinuses , engorged veins, visible pulsations .
Hernial orifices are free.

Palpitation :
Abdomen is soft and tenderness present in right hypochondrium
No organomegaly.

Percussion :
Tympanic note heard over the abdomen.

Auscultation:
Bowel sounds are heard.

RESPIRATORY SYSTEM:
Inspection: 
Shape- elliptical 
B/L symmetrical , 
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations 

Palpation:
Trachea - central
Expansion of chest is symmetrical. 
Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:
Bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes   Right    Left
Biceps      ++         ++
Triceps     ++          ++
Supinator  +              +
Knee         ++           ++
Ankle.        +             +






Diagnosis: Heart failure with cardiogenic pulmonary edema with bilateral pleural effusion. 
Hypervolemic hyponatremia secondary to heart failure 

K/c/o seizure disorder

Anaemia ( ? Iron deficiency anaemia)












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