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


Comments

Post a Comment

Popular posts from this blog

42yr old female suffering with multiple ailments

-
I have been given this case to solve and interpret to enhace my competency and as an attempt to understand the topic of  "patient clinical data analysis" You can find the entire clinical problem of the patient in this link  https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html   Priority of her complains according to my analysis 1) Severe headache associated with visual aura. loss of function & numbness  on left side  Falling to left side  Vertigo  csf rhinorrhea from left nostril  Aggravated by :stress,mensus, birth control pills  Headache was relieved by taking medication (triptans) Diagnosis : Most probably hemiplegic migraine Differential diagnosis may be  Space occupying lesion on right side.                                        I ncreased ICT  Secondary headache syndrome Cerebral vasculitis ( presents as headache & neurological deficit )   HEMIPLEGIC MIGRAINE       What Causes Them? So far, researchers have found four genes
Read more

pain abdomen secondary to uncontrolled sugars with DKA with ? pancreatitis with AKI on CKD. (CKD secondary to metabolic acidosis ) with HFPEF( EF- 58%) with metabolic acidosis secondary to DKA & CKD with H/o DM-2 , hypothyroidism , CKD

-
Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 43 year female came with complaints of pain abdomen & vomitings since 1 day HOPI : Patient was apparently asymptomatic 6 yrs back, then had anasarca , went to hospital in hyderabad &
Read more

26 yr old male with fever

-
Image
CBBLE UDHC Similar case This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 26 yr male mechanic by occupation came with c/o fever , since 5 days which is high grade , associated with chills , intermittent, relieved with medication .  No h/o v
Read more