A 65 years old male patient came to casualty with the complements of Distension of abdominen , shotness of breath,pedal edema.
15/7/23
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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.
Cheif complents:
C/o Distension of abdominen since 1 week
C/o Shortness of breath since 1 week
C/o pedal edema since 1 week.
History of presenting illness:
Patient was apparently asymptomatic 1 week ago then he develops shortness of breath grade 3-4. Continuous in onset and gradually progressive .
Dyspnea positive, PND positive.
Bilateral pedal edema, pitting type, extending untill knees .
Distension of abdominen since 1 week .
Cough - sputum with in normal colour non blood stained,non - foul smell.
History of past illness:
Patient was diagnosed with diabetes 10 years back , he went to hospital with complaints of burning micturition and pain in loin where he came to know that he has kidney problem and diabeties,since then he used metformin 500 mg and glimepiride 1 mg ,he worked as daily wage worker for 3 years after that he used to sell peanuts for 4 years and after COVID he stopped going to work.
All these years when he used to work his daily routine was that he used to get up at 4 in the morning does agricultural work and eats his breakfast at 8 in the morning -rice and curry , goes to work ,he eat his lunch at 1 - rice and curry and goes back to work,At 5 in the evening he comes back to home,and at around 8 he used to eat his dinner- rice and curry and goes back to sleep by 10.
After COVID he stopped working as he bstarted feeling weak ,his daily routine after COVID:
Wakes up at 5 walks for sometime comes home by 9 has his break fast - rice and curry,and lunch at 1 - rice and curry and dinner at 8 - rice and curry.
From last 15 days his daily routine: wakes up at 5 walks for some time and has 1st meal at 11 - rice and curry and again at night 8 - rice and curry and sleeps by 10.
Patient has history of alcohol consumption from when he was 30 years old daily 150 to 180 ml till 10 years back when hea was diagnosed with kidney problem he stopped consuming for 3 years and again started it till 10 days back ,since 10 days he started feeling abdominal discomfort and stoped consuming alcohol.
Family history
No family history.
Personal history :
Mixed diet. Adequate sleep.
Regular bowel movement.
Normal appetite
Normal bladder movement.
Occasional consumption of alcohol.
No history of smoking and chewing of Tobacco.
GENERAL EXAMINATION:
Prior consent was taken and patient was examined in a well lit room.
Patient was conscious, coherent and cooperative.
No pallor ,icterus, clubbing ,cyanosis.
bipedal edema present.
Temperature - 98.2°f.
BP - 110/60.
PR - 84 bpm.
RR - 22 cpm.
SPo2 - 98 %.
Systemic examination
Cvs :
Precordium normal
No thrills ,
On auscultation
S1,S2 heard ,no murmurs
CNS:
Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent
Rs:
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration
Trachea is central
Auscultation:
Normal vesicular breath sounds heard
P/A
INSPECTION:
Shape of abdomen:Distended
Umbilicus:inverted
Skin over the abdomen is shiny
All quadrants are moving equally with respiration
No visible peristalsis.
External genitalia normal
PALPATION:
Temperature:Not raised
Tenderness:Absent
No Rebound tenderness
No guarding rigidity
Percussion
No shifting dullness ,
No fluid thrill
Auscultation
Bowel sounds are heard
Investigations :
Hemogram,RFT ,LFT,2D echo ,Chest X - ray.
DIAGNOSIS:
Heart failure with preserved ejection fraction with wet beri beri.
Treatment :
1.Inj HAI s/c TID
Inj NPH s/c BD
2.INJ THIAMINE 100 mg in 100 ml / NS / IV / BD
3.INJ LASIX 40 MG PO/ BD
4.TAB MET- XL 12.5 MG PO/OD.
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