67 yr old male with SOB and B/L peadal edema
67 year old with sob and bilateral pedal edema
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A 67 year old male presented with shortness of breath and bilateral pedal edema.
K.Medha Reddy, 9th semester
Roll No: 51
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.
CASE:
A 67 year old male , farmer by occupation, came with chief complaints of
Bilateral Pedal edema since 6 months
Shortness of breath since 2months
Back pain since 2 months
History of present illness:
patient was apparently asymptomatic 2 years back then he developed shortness of breath on exertion, associated with dry cough for which he went to hospital, he took medication for shortness of breath.He used to take medication (inhalers)whenever he had shortness of breath.
Bilateral pedal edema upto knees since 6 months,which was insidious in onset and gradually progressive. It is pitting type.
He also complained of shortness of breath from 2 months which was insidious in onset and gradually progressed from grade 2 to grade 3 (NYHA) which is associated with PND and no history of orthopnea.
Patient complain of low back ache since 2 months which was insidious in onset gradually progressive .There is no radiation of pain . Pain is not relieved on medication. Pain aggravated since 1 week and was unable to sit or stand.
Past history:
He is a k/c/o COPD since 2 years and on medication.
No history of HTN, diabetes, epilepsy, TB
Personal history:
Appetite: Normal
Diet: Mixed
Sleep: adequate
Bowel and bladder: regular
Addictions:
occasional alcoholic, last intake 6 months back
History of smoking from 26 years but stopped 14 years back
Family history:
No significant family historyhistory
GENERAL EXAMINATION:
Patient is conscious, cohorent,cooperative and well oriented to time, place and person.
He is obese with distended abdomen
Pallor- absent
Icterus- absent
Clubbing-absent
Lymphadenopathy- absent
Cyanosis- absent
Pedal edema - present (B/L grade 2)
VITALS: on 31.03.2022(12.00pm)
B.P:110/70 mmhg
P.R:116bpm
R.R: 14cpm
Temp:101 F
SPO2: 99%@15L O2
GRBS: 152mg/dl
SYSTEMIC EXAMINATION:
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Moving equally with respiration on both sides
Type of respiration: abdomino thoracic.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Vocal fremitus- normal on both sides
Measurements:
Anteroposterior diameter- 21cm
Transverse diameter-30cm
Ratio: AP/T- 0.7
Chest expansion: 2.5 cm
Percussion:
Equally resonant on both sides
(Examined areas - Supra clavicular ,Infra clavicular, Mammary, Axillary, Infra axillary, Supra scapular, Infra scapular, Inter scapular)
Auscultation: Right Left
Supra clavicular: NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: NVBS NVBS Axillary: NVBS NVBS
Infra axillary: NVBS NVBS
Supra scapular: NVBS NVBS
Infra scapular: NVBS NVBS
Inter scapular: NVBS NVBS
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest- normal
No precordial bulge or pulsations
JVP - not raised
Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard No murmurs .
PER ABDOMEN :
soft , non tender
Umbilicus - inverted
All quadrants moving equally with Respiration
No scars , sinuses, engorged veins
No palpable spleen and liver
Normal bowel sounds heard.
CENTRAL NERVOUS SYSTEM:
All higher mental functions, motor system, sensory system and cranial nerves- intact.
RT LFT
BICEPS- 1+ 1+
TRICEPS- 1+ 1+
SUPINATOR- 1+ 1+
ANKLE - 1+ 1+
KNEE- 1+ 1+
At present:
INVESTIGATIONS:
31.03.2022
30.03.2022
29.03.2022
28.03.2022
25.03.2022( ADMISSION)
TROPONIN-I - negative
Ph-7.4
Pco2- 43.3
Po2-97.4
So2-95
Hco3-26.7
On 4 ltrs o2
Blood group-A positive
RBS- 132 mg/dl
Blood urea- 50mg/dl
Hemogram:
Hb - 11 gm/dl
TLC - 12400
N/L/E/M-92/3/2/3
PCV-36.2.2
MCV-75.9.9
MCH-23.1
MCHC-30.4
RDW - CV-17.4
PLT- 2.30
NC/NC with neutrophilic leucocytosis
Serum creatinine- 0.9
LFT:
Tb - 1.71
Db- 0.50
SGOT(AST) - 41
SGPT(ALT) - 38
ALP-250
Tp-5.4
Albumin-2.98
A/G - 1.23
SERUM ELECTROLYTES:
Na+ - 141
K+ - 4.3
Cl - - 97
Phosphorous-3.6 mg/dl
Serum ca+2 - 9.2 mg/dl
ECG- on 25 .03. 22
Chest Xray:
25.03.2022
26.3.22
ORTHO REFERAL(28.03.2022)
Lateral view of abdominal X-ray:
Xray of abdomen and pelvis:-
X Ray of pelvis and hip joint:
2D ECHO:
USG:
At the time of admission : 25/3/22
At present: 31.03.2022
PROVISIONAL DIAGNOSIS:
COPD with RIGHT HEART FAILURE and OSTEOPOROSIS of lumbar spine
TREATMENT: 31.03.2022
Nebulisation with Dorolin, Butecort - 6th hourly
Inj Lasix 40mg IV BD (8am-4pm)
(Check B.P before giving lasix)
Tab Hydralazine 12.5mg PO/BD
Tab Ecosporin AV/75/20mgPO/OD
Tab Ultracet 1/2 tab QID
Intermittent CPAP for 4 hours (With gap of 2hrs during feeds)
Vitals monitoring every hourly
Inj Zolenframic acid 4mg IV STAT
TREATMENT UPDATES
27/3/22
S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E: No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Vitals:
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NON TENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
PROVISIONAL DIAGNOSIS:-
COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY
28/3/22
S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Vitals:
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
PROVISIONAL DIAGNOSIS:-
COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY
29/3/22
S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Vitals:
Temp:Afebrile
PR:116bpm
BP:100/60 mm of hg
RR-18cpm
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
PROVISIONAL DIAGNOSIS:
COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY
30/3/22
S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Vitals:
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
PROVISIONAL DIAGNOSIS:
COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY
31-03-22
S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Vitals:
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+
PROVISIONAL DIAGNOSIS:
COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION
P:
Nebulisation with Dorolin, Butecort - 6th hourly
Inj Lasix 40mg IV BD (8am-4pm)
(Check B.P before giving lasix)
Tab Hydralazine 12.5mg PO/BD
Tab Ecosporin AV/75/20mgPO/OD
Tab Ultracet 1/2 tab QID
Intermittent CPAP for 4 hours (With gap of 2hrs during feeds)
Vitals monitoring every hourly
Inj Zolenframic acid 4mg IV STAT
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