50 year old male with SOB since 12 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.

Radhesh Mahankali.

A 50 year old male vegetable vender by occupation came to GM OPD with chief complaints of:

Shortness of breath since 12 days

HOPI:

Patient was apparently asymptomatic 3 months back, then he developed SOB [Grade IV(NYHA) : SOB even on rest and minimum physical activity].

The patient had complains of SOB with severe physical activity(grade II) 3-4 years ago, which progressed to current state.

H/o decreased urine output.

H/o orthopnea, paroxysmal nocturnal dyspnea.

H/o pedal edema [present below the knee and of pitting type].

H/o cough since 12days(non productive).

No h/o palpitations, chest pain, sweating, fever, cold, headache, myalgia .

PAST HISTORY: 

The patient got admitted for similar complaints 3 months ago (january)  got treated and discharged.

K/c/o Heart failure with CKD.

K/c/o HTN since 3 months for which he is using (Tab.HYDRALAZINE 12.5MG PO/OD)

N/k/c/o DM, Asthma, TB, epilepsy,etc

PERSONAL HISTORY:

Diet: mixed.

Appetite: decreased since 12 days.

Sleep: disturbed due to SOB.

Bladder: Decreased since 12 days with burning micturition.

Bowel: Normal

Addictions:

1) Alcoholic since 10 years( drinks half a bottle per day everyday). Last consumption was 15 days back.

2) Tobacco chewing(khaini) since 10 years(1-2 packets per day every day).

Allergies: No known allergies.

FAMILY HISTORY:

Not significant.

VITALS:

Temperature: 98.6°F.

PR: 80bpm.

RR: 27cpm.

BP: 150/90 mm hg.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, well oriented to time place and person.

No pallor.

No icterus.

No cyanosis.

No lymphadenopathy.

Clubbing present.

Pedal edema present [below the knee and of pitting type].

CVS EXAMINATION:

S1&S2 heard.

JVP Elevated.

RESPIRATORY SYSTEM EXAMINATION:

Normal vescicular breath sounds are heard.

P/A: SOFT AND NON TENDER.

CNS: NO FOCAL NEUROLOGICAL DEFICITS.

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH CKD , PLEURAL EFFUSION AND HYPERTENSION{ SINCE 3 MONTHS}.

 

TREATMENT:

1.FLUID RESTRICTION <1LT/DAY

2.SALT RESTRICTION <2GM/DAY

3.INJ.LASIX 60MG IV/BD

4.INJ.THIAMINE 200MG/IV/TID (in 100ml NS)

5.TAB.METAPROLOL 25MG PO/OD

6.TAB.ECOSPORIN AV 75(10)/PO/HS

7.T.NODOSIS 500MG PO/BD

8.CAP.BIO D3 PO/ONCE WEEKLY

9.PROTEIN RICH DIET 2EGG WHITES/DAY

FOLLOW UP: [28/03/2023]

grade II B/L pitting type pedal edema

SOB decreased 

Pt is c/c/c

Temp - 98.6°F

Bp - 120/80mmhg

Pr - 72bpm

RR - 20cpm

SpO2- 98% @ RA

GRBS:106mg/dl

CVS - S1 S2 heard , no murmurs

            JVP elevated

Rs -Rt IA Crepts present, decreased air entry on rt IA region

P/A: Soft,non tender

CNS - HMF+,NFND

T/T (28/03/2023):

1. FLUID RESTRICTION <1LT/DAY

2.SALT RESTRICTION <2GM/DAY

3.INJ.LASIX 60MG IV/BD

4.TAB.BENFOTHIAMINE 200 MG PO/BD

5.TAB.METAPROLOL 25MG PO/OD

6.TAB.ECOSPORIN AV 75(10)/PO/HS

7.TAB.CINOD 10MG PO/OD

8.CAP.BIO D3 PO/ONCE WEEKLY

9.TAB.NODOSIS 500 MG/PO/BD

10.PROTEIN RICH DIET 2EGG WHITES/DAY

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