A case of 60yrs old with shortness of breath

 Makkena Naga Varsha 

MBBS 9th semester

Roll no:76

This is 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 patients 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 comment box is welcome .

 

I’ve 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 .

Following is the view of my case..

A 60 year old male with presented to the OPD with chief complaints of

• Shortness of breath since 2 days 
• Chest pain since 2hours 

HISTORY OF PRESENTING ILLNESS :

The patient was apparently asymptomatic 25years ago, diagnosed to be diabetic as he had history of Loss of consciousness while he was going to washroom. He was on irregular medication and stopped As sugar levels are normal. Since six years he’s on regular medication again. 

History of pedal edema two years back Which is progressively increasing and pitting type.

Shortness of breath which is of grade 4 Since one year Worsening since one week aggravated on lying and relieved on sitting position and not associated with chest pains, palpitations.

PAST HISTORY : 

history of similar complaints in the past

known case of DM since 25yrs and HTN since 10-12yrs

No history of surgeries, blood transfusions.

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

Addictions: consumes alcohol daily for the past 20 years(90-180ml/ day). 

FAMILY HISTORY:

No history of similar complaints in the family.

No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.

GENERAL EXAMINATION: 

The patient is examined in a well lit room, with informed consent

The patient is conscious, coherent, cooperative, is well oriented to time, place, person.

He is moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : present 

VITALS

Temperature-afebrile

Heart rate- 84beats/min

Blood pressure- 140/90 mmHg

Respiratory rate- 20cycles/min

SPO2- 96% at room air

SYSTEMIC EXAMINATION:

 CVS: S1 and S2 heard

         No added thrills, murmurs

Respiratory system : normal vesicular breath sounds heard, position of trachea central,    no adventitious sounds heard, no dyspnea and wheeze.

 Per abdomen:  obese, tender, no palpable mass, no free fluid present, no organomegaly.

  On auscultation- bowel sounds are not heard 

Central nervous system:

Level of consciousness : conscious to time, place, person

Speech: normal

Cranial nerves -Normal

Motor and sensory: normal 

INVESTIGATIONS:

 

  RENAL FUNCTION TESTS-

   Urea: 108mg/dl
   Creatinine: 6.3mg/dl

   Calcium: 7.5

   Phosphate: 4.2

   Sodium: 139

   Potassium: 4.3

   Chloride: 99

LIVER FUNCTION TESTS-   

Total bilirubin=0.77mg/dl
Direct bilirubin=0.18mg/dl
AST: 24 IU/L
ALT: 11 IU/L
ALP:225 IU/L
Albumin: 3.3
Total Protein: 6
A/G Ratio:1.23

ECG

PROVISIONAL DIAGNOSIS:

Heart failure with preserved injection fraction 

Chronic renal failure

2nd° diabetic nephropathy

Grade 2 Prostomegaly

TREATMENT REGIMEN:

1. Fluid restriction <1.5L/day
2. Salt restriction <2g/day
3. Inj lasix 40mg BD.IV
4. Tab ecospirn AV (75/20) PO HS
5. Tab cardvas 3.125 mg PO OD
6. Tab amlog 5mg PO OD 
7. Tab vildagliptin 50mg PO OD
8. Tab tamsulosin 0.4mg PO H/S 
9. Propped up posture
10. O2 inhalation 
11. Inj Erythropoietin 4000units/ SC / weekly once