1801006100 CASE PRESENTATION

 long case

CHIEF COMPLAINT:
A 42 year old male patient was brought to casuality with chief complaints of bilateral lower limb swelling (pitting type) (l>r) since 15 days, and SOB since 2 days.
HISTORY OF PRESENT ILLNESS:
•Patient was apparently  asymptomatic 15 
days back  & then he noticed  bilateral 
lower limb swelling which was insidious in 
onset gradually progressing pitting type ( left 
more than right ) extending  up to the knees.

•Patient also complaining of breathlessness 
since 2 days which is Grade 2 initially 
progressed to Grade 3-4 associated with 
orthopnea & PND
No h/o cough, chest pain 
No h/o pain abdomen, vomiting, loose stools jaundice 
No h/o decreased urine output/ burning micturition and no other complaints 
HISTORY OF PAST ILLNESS:

He is not k/c/o DM , HTN , Bronchial Asthma , Epilepsy CVA CAD 
PERSONAL HISTORY:
Diet – Mixed 
Appetite – Decreased 
Sleep – Decreased 
Bladder & Bowel movements – 
Regular 
He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and  khaini 2-3 per day for the past 20 years.

FAMILY HISTORY

 no relavant family history 

TREATMENT HISTORY - 

No relavant treatment history 

GENERAL EXAMINATION
Patient is conscious,coherent,cooperative
Thin built & moderately nourished 
Pedal edema is  present 
No pallor, Icterus,cyanosis, clubbing, lymphadenopathy 

VITALS:
1.Temperature:- 98.6 F
2.Pulse rate: 110 beats per min , regular
3.Respiratory rate: 18 cycles per min
4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM

Inspection: 
•  Chest is barrel shaped, bilaterally 
symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•.  
JVP:Raised 
•Visible epigastric pulsations 
• No scars or sinuses
•Apical impulse seen in left 6th 
intercostal space lateral to mid 
clavicular line


Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Antero-posterior diameter of chest :Transverse  (5:7)
diameter of chest
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line
•Parasternal heave present (Grade-3)
•Palpable P2 + 
 
Auscultation: 
•S1 S2 heard
•No murmurs


RESPIRATORY SYSTEM:
Inspection: 
•Chest is barrel shaped, bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•Visible epigastric pulsations 
•No scars or sinuses
•Apical impulse seen in left 6th ICS lateral to MCL

Palpation:

•All inspectory findings are 

confirmed: 

Trachea is central, movements 

equal 

bilaterally. 

•Antero-posterior diameter of 

chest 

>Transverse diameter of chest

•Apex beat felt in 6th intercostal 

space lateral to midclavicular line

•Vocal fremitus decreased in 

right IAA & ISA

Percussion: 

•Dull note heard in right IAA & 

ISA

•Resonant note heard in all other 

areas bilaterally

 

Auscultation: 

•Bilateral air entry present – 

Normal vesicular breath sounds 

heard

•Breath sounds decreased in right 

IAA & 

ISA

•Vocal resonance decreased in 

right IAA & 

ISA

•Expiratory wheeze heard 

bilaterally

                                    

PER ABDOMEN:

•Scaphoid

•Visible epigastric pulsations

•No  engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present

 

CENTRAL NERVOUS 

SYSTEM:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

PROVISIONAL 

DIAGNOSIS : 

HEART FAILURE

RIGHT SIDED PLEURAL 

EFFUSION

COPD        

INVESTIGATIONS- 

Chest x ray 

Plueral fluid analysis

Volume -3ml

Appearance- clear

Colour- pale yellow

Total count- 10cells

DC= 100% L

RBC - nil

Others- nil

SERUM CREATININE 

1.1 mg/dl  ( normal 

0.9-1.3)

Blood urea - 21 mg/dl 

Hemoglobin - 11.3 

mg/dl

Usg findings -

right sided

PLEURAL 

EFFUSIONS  AND 

MILD 

ASCITIS

Ecg - 

2d echo 

                              

                              

2D ECHO:

 Moderate to severe TR+ 

with PAH : mild MR+ , 

trivial AR + 

Global akinetic , no AS/MS 

severe LV dysfunction.

No diastolic dysfunction, 

No LV clot. 

HFrEF with EF=27%

                              

FINAL DIAGNOSIS:

HFrEF ? 2° to CAD   

B/l PLEURAL EFFUSION (R 

> L)

   Copd 

      

Treatment : 

1) Fluid restriction <1lit/day 

2) Salt restriction. <2gm/day 

 3) Tab LASIX 40mg BD (8am to 4pm)

4) Tab MET-XL 25mg BD 

5) Tab ECOSPIRIN-AV 75/20 mg OD

6) Tab Telma 20mg

7) BP PR temp and spO2 monitoring

-----------------------------------------------------------------------------------------------------------------

short case

A 70year old came to the OPD with

Chief complaints of:

Bilateral pedal edema since 12days

Shortness of breath since 5days 

HOPI:

Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and is of pitting type.

He also developed Shortness of breath which was initially grade 1 and progressed to grade 2 (nyha)

Associated with orthopnea

H/o loss of appetite since one week and nausea three days back (3 episodes)

No H/o- fever,burning micturation, diarrhoea 

No H/o cough, hemoptysis,fever,

No h/o chest pain,giddiness , palpitations, decreased urine output, syncopal attacks,

No h/o abdominal distension, jaundice  vomitings

Past history:

Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD

Treatment history 

Not significant 

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-chronic alcoholic since 30years and Tobacco smoking since 40years.

Family history: Not significant 

General examination:

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

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Bilateral pedal edema is present,Upper limb edema

Vitals:

Temperature: 98.4 degree Fahrenheit

BP-100/80mmHg

PR-104bpm

RR-21cpm

Grbs- 147mg/dl

Systemic examination:

Respiratory system:

Inspection-

Trachea-central

Chest appears b/L symmetrical and elliptical in shape 

Palpation-

Trachea central in position 

Measurements- 

AP diameter-16cms 

Transverse diameter-26cms 

Percussion              

Supraclavicular - Resonant  on R&L                 

Infraclavicular -     Resonant  on R&L 

Mammary  -            Resonant  on R&L 

Axillary -                Dull on both right and left

Suprascapular -      Resonant  on R&L 

Infrascapular -         Dull on both right and left

Auscultation:

Decreased breath sounds at axillary and infrascapular region

CVS:

Inspection: 

•  Chest is  bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•. No parasternal haeve 
JVP:Raised 
•NO Visible epigastric pulsations 
• No scars or sinuses
•Apical impulse seen in left 6th 
intercostal space lateral to mid 
clavicular line


Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line

   Para sternal heave not seen

Auscultation: 
•S1 S2 heard
•No murmurs

Per abdomen: 

•Scaphoid

•Visible epigastric pulsations

•No  engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present

CNS:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

Provisional diagnosis: 

Left heart failure ?with bilateral pleural effusion 

Investigation:

Chest X-Ray:

Hemogram:

Hemoglobin-9.3gm/dl

Total count-12,800 cells/m3

Neutrophils-95%

Lymphocytes-62%

Eosinophils-0%

PCV-29.7 vol%

RDW-14.2%

USG:

Bilateral moderate pleural effusion with collapse of underlying lobes.

ECG - 

Blood sugar-80mg/d

Serum creatinine:1.4gm/dl

Blood urea - 21 mg/dl

FINAL DIAGNOSIS-  

heart failure with pleural effusion 

Treatment

*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.