53 y/o male with SOB, abdominal distension, pedal edema

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 available 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-centered online learning portfolio and your valuable inputs on the comment box is welcome.


Unit 1

Interns

Dr. Sravya Kandala
Dr. Navya
Dr. Raheem
Dr. Gnanadha
Dr. Chetana
Dr. Ashfaq

Dr. Charan PGY1
Dr. Vamsi PGY1
Dr. Sushmitha PGY2
Dr. Adithya PGY3
Dr. Praneeth PGY3
Dr. Praveen Naik Ass. Prof.
Dr. RAKESH BISWAS HOD


Here is a case I've seen:
Admission under Unit 1 on 08/02/2021

54 year old male patient who is a storekeeper by occupation came with shortness of breath since 4 months and abdominal distension since 2 months.
Patient was apparently symptomatic 4 months ago and then developed shortness of breath 4 months ago which was insidious in onset and gradually progressive(Grade III NYHA). SOB aggravated recently with ordinary physical activities like taking a bath.
H/o abdominal distension since 2 months which was insidious in onset and gradually progressive to the present size.
H/o bilateral pedal edema since 2 months, pitting type upto knee.
H/o constipation since 1 week.
No h/o dry cough ,orthopnea, PND, chest pain, syncope, palpitations.
No h/o vomitings, abdominal pain, loose stools, fever.
No h/o burning micturition, decreased urine output.

Past history
K/c/o DM - II since 15 years - on medication(Metformin BD)and Insulin (25u) OD.
K/c/o HTN since 5-6 years (Clinidipine 20 mg BD)
H/o Tuberculosis 6 years ago - used ATT for 6 months.

Personal history
Mixed diet
Loss of appetite since 4 months
Bowel movements - irregular (alternate days)
Sleep - adequate
Addiction - Consumes 90 ml of alcohol twice a week since 25 years, stopped one year ago.

No known allergies.

No significant family history.

General Examination

Pt. Is conscious, coherent, cooperative.

Pallor +
B/L pedal edema + (pitting type, upto knees)
No signs of icterus, cyanosis, clubbing, generalized lymphadenopathy

Vitals
PR - 84 bpm
BP - 140/80 mm Hg
RR - 18 cpm
Temp- 98.4 F

Weight - 81 kgs
Height - 175 cms
BMI - 26.4

Head to toe examination

Lipodystrophic pear shaped body
Frank sign +
Mallempati Grade III
Gynecomastia +
Diabetic dermopathy +

Systemic Examination

PA
Inspection
shape of the abdomen - obese
Inverted umbilicus
No scars, sinuses, engorged veins

Palpation
no local rise of temperature, no tenderness
Consistency - Soft
Liver & Spleen - not palpable
Abdominal girth - 110 cm

Auscultation
Bowel Sounds heard

CVS 
S1, S2 heard.
Feeble apex
Palpable P2
Pansystolic murmur accentuated with inspiration along left sternal border (Grade I - II)

CNS
Reflexes. Right. Left
Biceps. 2+. 2+
Triceps 2+. 2+
Knee. 1+. 1+      
Ankle. absent. absent
Plantar. Flexor. Flexor

RS
Lungs - clear on auscultation, BAE +
No added sounds 



Investigations :

Chest X ray PA view


ECG

2D echo

USG on 6/2/21


USG on 8/2/21






















Diagnosis

                   HFpEF WITH METABOLIC SYNDROME
                   CHRONIC LIVER DISEASE , HBsAg (+)

Treatment 

1. Inj. HAI s/c (8u) TID
inj. NPH 8u s/c BD
 with GRBS monitoring (6th hourly)
2. Tab. Lasix 40 mg BD
3. Tab. Clinidipine 20mg OD
4. BP/PR/Temp 4th hourly monitoring




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