70 year old male with SOB, pedal edema

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

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 Elog also reflects my patient centered 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.


Case scenario:

A 70 year old male, resident of suryapet came with the chief complaints of breathlessness and bilateral pedal edema, facial puffiness since 6 months.

History of present illness: 

Patient was apparently asymptomatic 6 months back. Later he developed shortness of breath which was gradual in onset, with duration of 6 months, gradually progressive and aggravating on walking and sleeping. Not relieved on medication (prescribed by local RMP). He also developed bilateral pedal edema along with facial puffiness which was gradual in onset, progressive in nature and relieved on medication. 
No h/o fever, cough, running nose, decreased urine output, burning micturition. 


Past history:

H/o of polio in childhood. (Affected his lower limb
No H/o similar complaints in the past
Not a known case of Hypertension, TB,Bronchial Asthma,thyroid, CAD.

Personal history:
Diet: Mixed
Appetite: Normal
Sleep:Adequate
Bowel and bladder movements: Regular
Allergies:No
Addictions: chronic alcoholic since 50 yrs(90 ml), chronic smoker since 50 yrs (5 chuttas/day)


Family history:
No H/o Similar complaints in the family.

General examination:
Patient is conscious coherent and cooperative 
Moderately built and moderately nourished 
 Well oriented to time place and person

VITALS 
TEMPERATURE: afebrile
Pulse rate: 65bpm
BP: 110/80 mmhg
Spo2:99%. At room air

Pallor present 
No icterus 
No cyanosis 
No clubbing 
No lymphadenopathy
Pedal edema (pitting type)


RESPIRATORY SYSTEM 
Raised JVP
Normal vesicular breath sounds heard
Trachea: central
No wheeze

 
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness 
No palpable mass
Liver not palpable

CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmurs heard 


Investigations: 

ECG

USG

2D Echo

CBP  
     Haemoglobin: 10 
     TLC: 6200 
     P c : 2.17 lakh/cumm
     Esonophill : 10 
     CUE :  
               colour = pale yellow 
                Reaction = acidic 
                Pus cells =2 to 3 
                Epithelial cells = 2 to 3 
    RBS : 143 mg/dl  
   Na + : 142 mEq /liter 
   K+ : 4.5 mEq/ liter 
   Cl- : 98 m Eq / liter 
   ABG : 
         ph = 7.31 
         Pco2 = 30.3 
         Po2 = 40.6 
         Hco3 - = 15.2
  Serum creatinine : 3.3 
  Urea : 77 
  LFT :  
      TB = 0.6 
       

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