A 65 year old male with complaints of SOB since 15 days , abdominal distension and pedal odema since 3 days.
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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 diagnosis and treatment plan.
CASE:
Patient is a 65 yr old male with
chief complaints of sob since 15 days , abdominal distension, pedal odema since 1 week.
HOPI:
Pt was apparently asymptomatic 15 days ago then he developed shortness of breath (grade 3), insidious, progressive, noticed after having food,and on ordinary physical activity ,h/o orthopnea, pnd.
Then he developed abdominal distension since 1 week abdominal bloating ,no regurgitation , discomfort is felt, aggravated after having food .
He also developed pedal odema ( pitting type) since 1 week.
No h/o ,chest pain, palpitations.
No h/o decreased urine output ,fever ,cough ,cold .
No h/o abdominal pain, vomitings,loose stools
K/c/o DM 2 since 10 years.
Past history:
Not a k/c/o HTN,Asthma, epilepsy,TB,CAD
Personal history:
Patient was diagnosed with diabetes 10 years back , he went to hospital with complaints of burning micturition and pain in loin where he came to know that he has kidney problem and diabeties,since then he used metformin 500 mg and glimepiride 1 mg ,he worked as daily wage worker for 3 years after that he used to sell peanuts for 4 years and after COVID he stopped going to work.
All these years when he used to work his daily routine was that he used to get up at 4 in the morning does agricultural work and eats his breakfast at 8 in the morning -rice and curry , goes to work ,he eat his lunch at 1 - rice and curry and goes back to work,At 5 in the evening he comes back to home,and at around 8 he used to eat his dinner- rice and curry and goes back to sleep by 10.
After COVID he stopped working as he bstarted feeling weak ,his daily routine after COVID:
Wakes up at 5 walks for sometime comes home by 9 has his break fast - rice and curry,and lunch at 1 - rice and curry and dinner at 8 - rice and curry.
From last 15 days his daily routine: wakes up at 5 walks for some time and has 1st meal at 11 - rice and curry and again at night 8 - rice and curry and sleeps by 10.
Patient has history of alcohol consumption from when he was 30 years old daily 150 to 180 ml till 10 years back when hea was diagnosed with kidney problem he stopped consuming for 3 years and again started it till 10 days back ,since 10 days he started feeling abdominal discomfort and stoped consuming alcohol.
General examination:
No signs of Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Oedema
Vitals
Temp:98.5°F
Bp: 120/80 mmhg
PR: 90 bpm
RR: 19 cpm
Systemic examination
Cvs :
Precordium normal
No thrills ,
On auscultation
S1,S2 heard ,no murmurs
CNS:
Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent
Rs:
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration
Trachea is central
Auscultation:
Normal vesicular breath sounds heard
P/A
INSPECTION:
Shape of abdomen:Distended
Umbilicus:inverted
Skin over the abdomen is shiny
All quadrants are moving equally with respiration
No visible peristalsis.
External genitalia normal
PALPATION:
Temperature:Not raised
Tenderness:Absent
No Rebound tenderness
No guarding rigidity
Percussion
No shifting dullness ,
No fluid thrill
Auscultation
Bowel sounds are heard
DIAGNOSIS:
Heart failure with preserved ejection fraction with wet beri beri ?
Investigations:
14/7/23
RBS : 122 mg/dl
HbA1c : 6.8 %
Serum creatinine:1.9 mg/dl
Blood urea: 38 mg/dl
Serum sodium: 141 mmol/L
Serum potassium: 4.6 mmol/L
Serum chloride : 102 mmol/L
Serum Albumin: 4.3 g/dl
