1801006111 LONG CASE

CHIEF COMPLAINT:
A 42 year old male patient came to casuality with chief complaints of bilateral lower limb swelling  (left>right) since 15 days,  and shortness of breath since 2 days.

HISTORY OF PRESENTING ILLNESS:

•Patient was apparently asymptomatic 15 days later he noticed bilateral lower limb swelling which was insidious in onset gradually progressing pitting type ( left more than right ) extending up to the knees.
h/o of breathlessness since 2 days which is Grade 2 initially progressed to Grade 3-4 associated with orthopnea & PND.
No h/o cough, chest pain.
No h/o pain abdomen, vomiting, loose stools.
No h/o decreased urine output/ burning micturition and no other complaints.
No palpitations
No h/o syncopal attacks
No h/o wheeze hemoptysis
No h/o abdominal distension, fever, weightloss.

HISTORY OF PAST ILLNESS :
No similar complaints in the past.
No h/o DM , HTN ,ASTHMA, CVD, Epilepsy.

PERSONAL HISTORY:
Diet – Mixed
Appetite – Decreased
Sleep – Decreased
Bladder & Bowel movements – Regular.
He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and khaini 2-3 per day for the past 20 years.

FAMILY HISTORY:
no relevant family history.

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative.

Thin built & moderately nourished.

Pedal edema is  present 

No pallor,

No icterus.

No cyanosis, 

No clubbing,

No lymphadenopathy .

VITALS:1

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min , regular

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A .CARDIO VASCULAR SYSTEM 

Inspection: 

•Chest is barrel shaped, bilaterally symmetrical.

•Trachea is central 

•Movements are equal bilaterally

•JVP:Raised 

•Visible epigastric pulsations 

•No scars or sinuses

•Apical impulse seen in left 6th intercostal space lateral

to midclavicular line .

Palpation-

•All inspectory findings are confirmed: 

Trachea is central, movements equal bilaterally. 

•Antero-posterior diameter of chest >Transverse 

diameter of chest

•Apex beat felt in left 6th intercostal space lateral 

to midclavicular line

•Parasternal heave present (Grade-3)

•Palpable P2 + 

Auscultation: 

•S1 S2 heard

•No murmurs

B.RESPIRATORY SYSTEM:

Inspection: 

Chest is barrel shaped, bilaterally symmetrical.•

.Trachea is central 

•Movements are equal bilaterally

•Visible epigastric pulsations 

•No scars or sinuses

•Apical impulse seen in left 6th ICS lateral to MCL

Palpation:

•All inspectory findings are confirmed: 

Trachea is central, movements equal 

bilaterally. 

•Antero-posterior diameter of chest 

>Transverse diameter of chest

•Apex beat felt in 6th intercostal space

 lateral to midclavicular line

•Vocal fremitus decreased in right IAA 

& ISA.

PER ABDOMEN:

•Scaphoid

•Visible epigastric pulsations

•No engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present



CENTRAL NERVOUS SYSTEM:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

PROVISIONAL DIAGNOSIS:

HEART FAILURE

RIGHT SIDED PLEURAL EFFUSION

COPD.

INVESTIGATIONS :

CXR 

Plueral fluid analysis

Volume -3ml
Appearance- clear
Colour- pale yellow
Total count- 10cells
DC= 100% L
RBC - nil
Others- nil

SERUM CREATININE 

1.1 mg/dl ( normal 

0.9-1.3)

Blood urea - 21 mg/dl 

Hemoglobin - 11.3 mg/dl

USG Findings:

Right sided PLEURAL EFFUSION AND MILD ASCITES.

ECG :


FINAL DIAGNOSIS:

HFrEF ? 2° to CAD   

B/l PLEURAL EFFUSION (R > L)

COPD.

Treatment : 
1) Fluid restriction <1lit/day 
2) Salt restriction. <2gm/day 
 3) Tab LASIX 40mg BD (8am to 4pm)
4) Tab MET-XL 25mg BD 
5) Tab ECOSPIRIN-AV 75/20 mg OD
6) Tab Telma 20mg
7) BP PR temp and spO2 monitoring.




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