65 yr old male with SOB since 15 days, abd distension and pedal edema since 1 week

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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.

 

CASE:

Patient is a 65 yr old male with 

chief complaints of sob since 15 days , abdominal distension, pedal odema since 1 week.

HOPI:

Pt was apparently asymptomatic 15 days ago then he developed shortness of breath (grade 3), insidious, progressive, noticed after having food,and on ordinary physical activity ,h/o orthopnea, pnd.

Then he developed abdominal distension since 1 week abdominal bloating ,no regurgitation , discomfort is felt, aggravated after having food .

He also developed pedal odema ( pitting type) since 1 week.

No h/o ,chest pain, palpitations.

No h/o decreased urine output ,fever ,cough ,cold .

No h/o abdominal pain, vomitings,loose stools

K/c/o DM 2 since 10 years.

Not a k/c/o HTN,Asthma, epilepsy,TB,CAD 

Personal history:

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.

Vitals:

Pallor 

Cyanosis

Clubbing 

Lymphadenopathy

Oedema 

Vitals

Temp:98.5°F 

Bp: 120/80 mmhg 

PR: 90 bpm

RR: 19 cpm

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.

DIAGNOSIS:

Heart failure with preserved ejection fraction with wet beri beri ?

Investigations:

14/7/23 

RBS : 122 mg/dl

HbA1c : 6.8 %

Serum creatinine:1.9 mg/dl

Blood urea: 38 mg/dl

Serum sodium: 141 mmol/L

Serum potassium: 4.6 mmol/L

Serum chloride : 102 mmol/L

Serum Albumin: 4.3 g/dl

2Decho:

USG:

Chest X RAY:

ECG:

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