85yr old male with pedal edema, SOB, decresed urine output

The entire analysis of this case is found in the link below

https://mohithak.blogspot.com/2021/03/dr-mohitha-dr-supriya-dr-sanjay-dr.html

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis and to develop competency in reading & comprehending clinical data including history,clinical findings,investigations & come up with a diagnosis & treatment plan

85year old male came to casuality on 4/3/21 with 

CHEIF COMPLAINTS :

1. PEDAL EDEMA SINCE 7 DAYS

– which  is insidious in onset and gradual progression of pedal edema up to thighs(gradelll) and there is associated abdominal distension.

The causes for pedal edema may be due to cardiac or renal .

As there is no periorbital puffiness we can rule out renal cause. 

There is raised JVP . So pedal edema may be secondary to right heart failure

2.SHORTNESS OF BREATH SINCE 7 DAYS

– H/O shortness of breath since 7 days which was insidious in onset gradually progressed from grade l to ll,increased on exertion,relieved on rest ,associated with wheeze, orthopnea, PND 

– No diurnal/ seasonal variation.

Dyspnea may be due to cardiac or respiratoy pathology

PATHOGENESIS OF CARDIAC DYSPNEA

1  decrease Vital capacity due to blood in lung

 2 Exaggeration of Hering-Beruer reflex due to rigid alveali.

 3 Churchil- Cope reflex in pul. congestion stimulate RC

4 Pulmonary edema nonfunctioning alveoli 

5 Fatigue of resp. ms

6 Pleural & pericardial effusion compression of lung

7 Hypoxia stimulate RC.

3. COUGH SINCE 7 DAYS

– Associated with scanty mucoid expectoration . Cough aggravated on sleeping and relieved with medication, there is history of fever,wheeze, chest discomfort 

– There is h/o similar complaints of productive cough with fever (1 month back) which may suggest chronic bronchitis 

Other possible causes of cough with expectoration :-

Pneumonia

COPD

Cystic fibrosis

Asthma

4. DECREASED URINE OUTPUT SINCE 7 DAYS 

The possible differentials :

There is no history of hematuria (ruling out Glomerulonephritis) ,

 

no history of dribbling of urine (BPH),

 no h/o burning micturition (infection,sepsis), 

no h/o pain during urination ( calculus ) .

 So oliguria may be secondary to heart failure.

PAST HISTORY

Not a k/c/o DM,HTN,CVA,CAD,TB,ASTHMA,EPILEPSY

PERSONAL HISTORY

Mixed diet 

Appetite decreased

Sleep is not adequate due to PND,  cough

Bowel &  bladder  : bowel habits are regular, but there is decreased urine output

ADDICTIONS: he used to smoke 5chutta / day. But ceased smoking 10 years back. 

Occionally consumes 50 ml alcohol 

GENERAL EXAMINATION 

Patient conscious,coherent,co-operative, 

pallor,icterus

Pedal edema - B/L pitting type grade - 2

No cyanosis,clubbing,generalised lymphadenopathy

VITALS

temp- afebrile

Bp- 140/90mm hg

PR- 96bpm

RR-18cpm

SpO2-94% at RA

SYSTEMIC EXAMINATION 

CVS

INSPECTION : Raised JVP 

B/L ear lobe crease ( frank sign +ve )

PALPATION : diffuse apex beat 

AUSCULTATION :  s1, s2 heard 

          No murmurs

RS- B/l AE+

        NVBS heard

P/A- 

soft, tenderness in rt. Upper quadrant bowel sounds heard

(Tenderness may be because of congestion of liver  )

CNS- NAD

1. ANATOMICAL LOCATION INVOLVED :

HEART 

2. PATHOLOGICAL DIAGNOSIS 

Heart failure 

Evidences suggesting HF in this case :

In History : pnd, orthopnea 

Examination : Raised JVP- right heart failure 

diffuse apex beat - RVH

Frank sign +ve suggesting IHD

Xray : cadiomegaly and double contour on left side suggesting RVH

ECG : RBBB (rsR pattern in V1)

3.ETIOLOGICAL DIAGNOSIS : 

1. Heart failure secondary to aging. &  associated atherosclerosis, IHD ( frank's sign +ve i.e B/L ear lobe creases. echo showing sclerosis of aortic valve. )

2.  left heart failure leading to rt. Heart failure ( cardiomegaly in xray showing LVH, & double contour suggesting RVH)

3. TREATMENT GIVEN

1.LASIX

Rationale :  promotes Diuresis - decreases edema  , 

decreases preload - Decreases congestive symptoms

2.TAB ATORVASTATIN 40mg/PO/OD

Rationale : To stabilize the plaque

3.TAB ASPIRIN 75mg/PO/OD

TAB CLOPIDOGREL 75MG/PO/OD

Rationale : Antiplatelets 

Above treatment is given as prophylaxis to prevent thromboembolic events