42 year old male with Dyspnoea , abdominal distention and pedal edema

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Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 plan.

M.Abhignya      9th sem

 42 yr old male electrician, came to casualty with cheif complaint of 

1. SOB grade 4 , progressed from grade 3 since 4-5days 

2.abdominal distension since 4-5 days

3. Bilateral pedal edema upto ankle since 4-5 days .

1yr back diagnosed as TB , used medication for 4days and stopped.

Patient was apparently asymptomatic till July 21 when  he was admitted here in Kims ,nkp, with symptoms of 

 SOB , pedal edema , diagnosed as HFrEF with EF= 32% , with COPD, with LEFT ULCER ON FOOT  managed conservatively with diuretics, beta blockers , one episode of AF ( paroxysmal) resolved.

refer this elog for previous history

http://93harika.blogspot.com/2021/10/42-yr-old-male-electrician-came-to.html

Patient continued to consume alcohool 15days after discharge 

with increased binge drinking since 10days , followed by cough, productive, no diurnal variation ,

associated with  low grade fever  and SOB , progressed to grade 4 gradually, associated with orthopnea ,

 with abdominal distension and bilateral pedal edema upto knee

Past history

Not a k/c/o diabetes/ hypertension/ asthma/epilepsy.

K/c/o alcoholic 180ml whiskey/day since 20yrs .

Gutka consumption since 20yrs.

No similar complaints in the past.

Personal history

Diet - mixed 

Appetite - decreased

Bowel and bladder movements - regular

No allergies

No addictions

 

Family history - not significant 

GENERAL EXAMINATION

On 18.10.21

Patient is conscious, coherent,co operative.

Thin built and poorly nourished

No pallor ,Icterus , cyanosis , clubbing, lymphedenopathy

bilateral pedal edema upto knee

VITALS

Afebrile

BP: 90/60mmhg

PR- 112bpm

RESP. RATE: 34CPM

Spo2: 89% room air

CVS:

Parasternal heave +

Apex - visible, diffuse.

S1,S2 heard.

JVP raised

video link

https://youtu.be/VH4WtlqkUjA

 - https://youtube.com/shorts/VH4WtlqkUjA?feature=share

RESPIRATORY SYSTEM:

 Dyspnea- grade 4

Wheeze + , bilateral end inspiration.

Position of trachea - central

Adventitious sounds :

Rhonchi + , rales+ , in bilateral ISA . 

PER ABDOMEN:

Soft,Distended.

No any tenderness.

Shifting dullness+

Bowel sounds heard.

CNS : NAD.

INVESTIGATIONS:

On 18.10.21

Serum creatinine: 2.1

Blood urea : 75

Serology: negative

On 23.10.21

Serum creatinine: 2.2

Blood urea : 75

on 19.10.21

Arterial blood gas

               PH :     7.28

                Pco2   :40.9

                Po2:     44.2

                HCO3 : 18.7

              St.HCO3:18.7

               02 saturation : 96.3

On 21.10.21

                  PH :     7.21

                Pco2   :25.6

                Po2:     44.2

                HCO3 : 20.1

              St.HCO3:11.8

               02 saturation : 96.3

LIVER FUNCTION TEST

Total bilirubin  -  2.97

Direct bilirubin - 0.90

AST -             262

ALT             - 171

Alkaline phosphate- 436

Total proteins - 5.5 

Albumin    -  1.15

0n 21.10.21

Total bilirubin  -  2.79

Direct bilirubin - 1.20

AST -             228

ALT             - 186

Alkaline phosphate- 433

Total proteins - 5.4

Albumin    -  2.4

 Serum electrolytes

sodium - 136

pottasium - 3.8

chloride - 97

magnesium - 1.8

calcium - 8.5

LDH = 431

ECG

 

                                                           on 18.10.21

on 19.10.21

CXR

2D ECHO:

https://youtu.be/bF_vZCBay3I

 video link-https://youtu.be/bF_vZCBay3I

 Moderate to severe TR+ with PAH : mild MR+ , trivial AR + 

Global akinetic , no AS/MS 

severe LV dysfunction.

No diastolic dysfunction, 

No  LV clot. 

 

PROVISIONAL DIAGNOSIS:

HFrEF with EF=27%

Acute decompensation of chronic heart failure 

With h/o paroxysmal AF (resolved)

With Right sided pleural effusion, secondary to 

     ?Consolidation- CAP

                               - TB

    cardiorenal type2 syndrome .

With left non healing ulcer over foot , DM - , HTN - .

with h/0 TB ( defaulter ) used medication for 4 days

TREATMENT:

1.  02 Inhalation @ 4Litres/min.

2 .propped up posture.

3 .fluid restriction < 1liter/day

4. Salt restriction < 2gm/day

5   .Inj. Lasix 40mg / i.v / TID ]

    If SBP > 100mmhg.

6.  Tab. Ecospirin-Av  75/20mg OD

7 . Inj. Thiamine 3amp /i.v / in 100ml NS stat  

8.  Neb with IPRAVENT , DUOLIN /stat 

      IPRAVENT= 8th hourly

       BUDECORT = 12th hourly.

9. Strict I/o monitoring.

10. BIPAP intermittently every 2hrs.

11.Foleys catheterization

12.Inj. Lasix 10amp (vials) 

      20ml.lasix + 30ml NS= 200mg.

      1ml= 200/50= 4mg.

At 2ml/hr ( 8mg/hr).

13.  T. Met Xl 25mg /po/stat

14.  Inj. HYDROCORTISONE 100mg/i.v /stat

PLEURAL TAP DONE .