67 year old male with bilateral pedal edema and shortness of breath

 This is 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 patients 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 comment box is welcome.

M Tharun Kumar, roll no.87

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 plan.  

CASE PRESENTATION :

A 67 year old male , farmer by occupation, came with chief complaints of

Bilateral Pedal edema since 6 months 

Shortness of breath since 2months

Back pain since 2 months

25/03/2022 

30/03/2022

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 2 years back then he developed shortness of breath on exertion, associated with dry cough for which he went to hospital, given medication for shortness of breath.He used to take medication   (inhalers)whenever he had shortness of breath.

 Bilateral pedal edema since 6 months,which was insidious in onset and gradually progressive. It is pitting time.

From the last 2 months shortness of breath which was of NYHA grade 2  progressed to grade 3 associated with PND. Patient complain of low back ache since 2 months which was insidious in onset gradually progressive .There is no radiation of pain . Pain is not relieved on medication.

Since one week pain was aggravated and patient was unable to sit or stand.

Past history:

No history of hypertension, diabetes, tuberculosis

No drug allergy.

Known case of COPD since 2yrs.

Personal history:

Diet- mixed

Appetite- normal 

Bowel and bladder movements- Regular 

Occasional alcoholic- last binge 6 months back 

Smoking history:  History of smoking for 26 years, stopped smoking from last 14 years.

FAMILY HISTORY: Not significant family history

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative 

No pallor, no icterus, no Cyanosis, no clubbing, no lymphadenopathy 

Bilateral pedal edema is present (pitting type)

 

VITALS- day 1

TEMP-101 F

BP-120/80 MM HG

PR-110 BPM

RR-28/min

SpO2-88% @ RA, 99,%@ 5 L OF O2

GRBS-133 MG/DL

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

Type of respiration: abdomino thoracic.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- present.

Vocal fremitus- normal on both sides

Measurements:

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapula

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

 Vesicular breath sounds

Rhonchi heard.

Decreased breath sounds.

Cardiovascular system:

JVP- raised.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Abdominal examination:

Abdomen distended, umbilicus- inverted

Soft, tenderness present

No organomegaly. 

 

Central nervous system:

No focal neurological deficit.

REFLEXES-

                        RT.                   LFT

BICEPS-.        1+.                      1+

TRICEPS-.      1+.                      1+

SUPINATOR- 1+.                       1+

ANKLE.        -. 1+.                       1+

KNEE-.            1+                         1+

INVESTIGATIONS:

Ph-7.4

Pco2- 43.3 

Po2-97.4

So2-95

Hco3-26.7

On 4 ltrs o2

Blood group-A positive 

RBS- 132 mg/dl

Blood urea- 50mg/dl

Hemogram:

Hb - 11 gm/dl

TLC - 12400

N/L/E/M-92/3/2/3

PCV-36.2.2

MCV-75.9.9

MCH-23.1

MCHC-30.4

RDW - CV-17.4

PLT- 2.30

NC/NC with neutrophilic leucocytosis

Phosphorous-3.6 mg/dl

Serum ca+2   - 9.2 mg/dl

Serum creatinine- 0.9

LFT:

Tb - 1.71

Db- 0.50

SGOT(AST) - 41

SGPT(ALT) - 38

ALP-250

Tp-5.4

Albumin-2.98

A/G - 1.23

SERUM ELECTROLYTES:

Na+ - 141

K+ -  4.3

Cl -  - 97 

 

USG:.                                                                              

 

PROVISIONAL DIAGNOSIS:

Right heart failure secondary to COPD with severe back pain under evaluation.

TREATMENT:

1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD

  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD

ORTHO REFERAL 

 

Day 2 :

BP.:120/80mmhg

PR.:88bpm

RR.:22/min

SPO2.:98% with oxygen

GRBS: 150mg/dl.

DAY 3:

BP.:110/70mmhg

PR.:86bpm

RR.:18/min

SPO2.: 98% with oxygen

GRBS: 109mg/dl.

1.NEBULISATION WITH SALBUTAMOL IPRAVENT AND BUDECORT-6th HOURLY

2.INJ LASIX 40 MG  IV/BD

  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD

DAY 4:

BP.:120/80mmhg

PR.:110bpm

RR.:22/min

SPO2.:99% at room air

GRBS: 100mg/dl.

1.NEBULISATION WITH SALBUTAMOL IPRAVENT AND BUDECORT-6th HOURLY

2.INJ LASIX 40 MG  IV/BD

  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD 

SOAP UPDATES

30/3/22

S-C/o SOB

PEDAL EDEMA DECREASED

Back pain not decreased 

O-

O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Temp:Afebrile

PR:102bpm

BP:100/70 mm of hg

RR-15cpm

SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .

P/A:SOFT,NONTENDER,BS+

CNS-PT CONSCIOUS,SPEECH NORMAL

CRANIAL NERVES-NORMAL

REFLEXES-

                        RT. LFT

BICEPS-.        1+. 1+

TRICEPS-.      1+. 1+

SUPINATOR-  1+. 1+

ANKLE. -.        1+. 1+

KNEE-.             1+ 1+.   

SOAP NOTES:

31/3/22

67YEAR/male

S-C/o SOB

PEDAL EDEMA DECREASED

O-

O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Temp:Afebrile

PR:102bpm

BP:110/70 mm of hg

RR-14 cpm

SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs

RS:BAE+, NVBS heard on left side and on right side wheeze and crepts are present .

P/A:SOFT,NON TENDER, BS +

CNS-PT CONSCIOUS,SPEECH NORMAL

CRANIAL NERVES-NORMAL

REFLEXES-

                        RT.     LFT

BICEPS-.        1+.       1+

TRICEPS-.      1+.       1+

SUPINATOR- 1+.       1+

ANKLE. -.       1+.       1+

KNEE-.            1+        1+

A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

Investigations: 

ABG:

Hemogram:

P-

1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD

  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTERMITTENT CPAP 4TH HOURLY

At present the pedal edema is decreased.