A 40 YR OLD MALE WITH GENERALIZED EDEMA AND SOB
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MUSKAAN GOYAL ,
ROLL NO. 92
September 27 , 2021
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 and treatment plan.
CASE DISCUSSION:
A 40yr old male pt driver by occupation , resident of chityal who is a chronic alcoholic presented to the Ops on 25/9/2021 with chief compliants of
GENERALIZED EDEMA SINCE ONE WEEK
HISTORY OF PRESENTING ILLNESS:
Pt. was apparently asymptomatic 3 years back and the he developed bilateral pedal edema whic was pitting type ,insidous in onset , and gradually progressive in nature upto knee region. For this complaints pt had gone to hospital 1 where he was admitted and treated for 3 days nd given medication for a month and advised to quit alcohol.
pt has now presented to our hospital with complaints of generalised edema since 1 week. The edema was insidious in onset and gradually progressive in nature which first appeared in both hands and gradually spread to upper abdomen nd later involved whole body i.e anasarca . This was associated with SOB which was first grade 2 and now is grade 4 .
orthopnea present , PND absent
dry cough present
NO h/o burning micturation , difficulty in voiding urine , presence of fever ,chest pain ,cold , abdomen pain , loose stools .
no history of intake of any food or drug .
NO history of DM , HTN, EPILEPSY , STROKE , CAD, THYROID DISORDERS. TB.
FAMILY HISTORY:
NO significant family history.
PERSONAL HISTORY:
diet : mixed
appetite: decreased
sleep: adequate
bowel and bladder: regular.
no known drug or food allergies
addictions: Pt. is a chronic alcoholic since 15 years . Drinks 250ml - 360ml of whisky everyday.
GENERAL EXAMINATION:
C/C/C
obesity present
pallor- absent
icterus- absent
clubbing- absent
cyanosis-absent
lymphadenopathy-absent
edema- present generalised pitting type.
SYSTEMIC EXAMINATION:
CVS: s1 s2 heard , no added murmurs , RAISED JVP.
RESPIRATORY: normal breadth sounds heard
decreased breadth sounds on right inframammary area
CNS: intact . no focal neurological deficits
ABDOMEN: distended
umbilicus: slit like
ascites present: shifting dullness felt.
INVESTIGATIONS:
1. ECG
ON 27/9/2020
2. 2D ECHO:
3. USG ABDOMEN
4. BLOOD PROFILE , LFT . SERUM CREATININE AND ELECTROLYTES
5, PT: 15SEC
INR: 1.11
APTT: 31 SEC
TREATMENT BEING GIVEN:
DIAGNOSIS:
ANASARCA SECONDARY TO HEART FAILURE , HFPEF(EF:64%) CHRONIC ALCOHOLIC.
Diagnostic asicitic tap video
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