40 YR OLD MALE WITH GENERALIZED EDEMA AND SOB

40 YR OLD MALE WITH GENERALIZED EDEMA AND SOB

 September 27, 2021

 This is an online E log book to discuss our patient's de-identified health data shared after taking 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.

Tharun Kumar , ROLL NO. 87

 September 27 , 2021 

 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 diagnosis and treatment plan. 

 CASE DISCUSSION:

 A 40yr old male pt driver by occupation , resident of chityal who is a chronic alcoholic presented to the Ops on 25/9/2021 with chief compliants of GENERALIZED EDEMA SINCE ONE WEEK

HISTORY OF PRESENTING ILLNESS: 

Pt. was apparently asymptomatic 3 years back and the he developed bilateral pedal edema whic was pitting type ,insidous in onset , and gradually progressive in nature upto knee region. For this complaints pt had gone to hospital 1 where he was admitted and treated for 3 days nd given medication for a month and advised to quit alcohol. pt has now presented to our hospital with complaints of generalised edema since 1 week. The edema was insidious in onset and gradually progressive in nature which first appeared in both hands and gradually spread to upper abdomen nd later involved whole body i.e anasarca . This was associated with SOB which was first grade 2 and now is grade 4 . orthopnea present , PND absent dry cough present

  NO h/o burning micturation , difficulty in voiding urine , presence of fever ,chest pain ,cold , abdomen pain , loose stools . no history of intake of any food or drug .

NO history of DM , HTN, EPILEPSY , STROKE , CAD, THYROID DISORDERS. TB.

 FAMILY HISTORY: NO significant family history. 

 PERSONAL HISTORY: 

 

diet : mixed 

appetite: decreased

sleep: adequate

bowel and bladder: regular.

no known drug or food allergies

addictions: Pt. is a chronic alcoholic since 15 years . Drinks 250ml - 360ml of whisky everyday. 

GENERAL EXAMINATION: C/C/C obesity present pallor- absent 

icterus- absent

clubbing- absent

cyanosis-absent

 lymphadenopathy-absent 

 edema- present generalised pitting type.

 

SYSTEMIC EXAMINATION:

CVS: s1 s2 heard , no added murmurs , RAISED JVP.

RESPIRATORY: normal breadth sounds heard

decreased breadth sounds on right inframammary area

CNS: intact . no focal neurological deficits

ABDOMEN: distended

                    umbilicus: slit like 

                   ascites present: shifting dullness felt.

Investigations:

ECG: 

27/09/2020

29/09/2020

2D Echo :

USG Abdomen :

BLOOD PROFILE , LFT . SERUM CREATININE AND ELECTROLYTES

5, PT: 15SEC

INR: 1.11

APTT: 31 SEC

TREATMENT BEING GIVEN:

DIAGNOSIS:

ANASARCA SECONDARY TO HEART FAILURE , HFPEF(EF:64%) CHRONIC ALCOHOLIC.

Diagnostic asicitic tap video

https://youtu.be/XIUsUAy4Atg