53 y/o male with SOB, abdominal distension, pedal edema
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Unit 1
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
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
