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