67YR OLD WITH SOB, BILATERAL PEDAL EDEMA AND LOW BACKACHE

 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 a diagnosis and treatment plan.  

PREFINAL CASE REPORT:

A 67 year old male who is farmer by occupation in past came to hospital on 25.03.2022 with chief complaints of

Bilateral pedal edema since 6 months
Shortness of breath since 2 months

Low backache since 2 months

 

HOPI : Patient was apparently asymptomatic 2 years back then he developed shorthness of breath on exertion and also associated with dry cough then he consulted local hospital there he was put on medication (inhaler) which helped in relieving SOB, later he had similar episodes from then which decreased on medication.

Now 6 months back he developed bilateral pitting type of pedal edema till knee level which is insidious in onset gradual in progression.

Then 2 months back again he had shorthness of breath which started in grade 2 and progressed to

grade 3 ( NYHA) and associated with PND

No history of orthopnea

He aslo complaints of low backache which is insidious in onset, gradual in progression, not radiated to any other areas and not relieved on medication. 

1 week back this pain progressed to such a severity that he can't sit or stand

Now he is able to sit with support of hands but can't stand.

Now he came to hospital on 25.03.2022 with grade 4 SOB (NYHA)

PAST HISTORY:

He is a k/c/o COPD since 2 years and on medication

No history of HTN, diabetes, epilepsy, TB

PERSONAL HISTORY:

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel and bladder: regular

Addictions: 

occasional alcoholic, last binge 6 months

History of smoking from 26 years but stopped 14 years back

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

He is obese with protruded abdomen

Pallor- absent

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

VITALS:31.03.2022(12.00pm)

B.P:110/70 mmhg

P.R:116bpm

R.R: 14cpm

Temp:101 F

SPO2: 99%@15L O2

GRBS: 152mg/dl

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

Moving equally with respiration on both sides

Type of respiration: abdomino thoracic.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Vocal fremitus- normal on both sides

Measurements:

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Percussion:      

             

Supra clavicular            

Infra clavicular.         

Mammary

Axillary

Infra axillary

Supra scapular

Infra scapular

Inter scapular

Right side and left side- resonant in above areas

Auscultation:              Right                  Left

Supra clavicular:       NVBS                  NVBS

Infra clavicular:         NVBS                  NVBS

Mammary:                   NVBS                  NVBS              Axillary:                       NVBS                  NVBS

Infra axillary:            NVBS                   NVBS

Supra scapular:         NVBS                   NVBS

Infra scapular:          NVBS                   NVBS

Inter scapular:          NVBS                   NVBS

Cardiovascular system:

Inspection:

Shape of chest normal

JVP- not raised

No precordial buldge, pulsations are seen

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

No murmurs

Abdominal examination:

soft , non tender

Umbilicus - inverted

All quadrants moving equally with Respiration 

No scars , sinuses, engorged veins 

No palpable spleen and liver

Normal bowel sounds heard.

Central nervous system:

All higher mental functions, motor system, sensory system and cranial nerves- intact.

REFLEXES-

                        RT      LFT

BICEPS-           1+      1+

TRICEPS-        1+      1+

SUPINATOR- 1+       1+

ANKLE  -        1+       1+

KNEE-             1+       1+

At present:

PROVISIONAL DIAGNOSIS : COPD WITH RIGHT HEART FAILURE and BACKACHE (under evaluation)

INVESTIGATIONS:

31.03.2022

30.03.2022

29.03.2022

28.03.2022

25.03.2022( ADMISSION)

TROPONIN-I - negative

Above Investigatons:-
Ph-7.4
Pco2- 43.3 
Po2-97.4
SPo2-95
Hco3-26.7
On 4 ltrs o2
Blood group-A positive 
RBS- 132 mg/dl
Blood urea- 50mg/dl

Hemogram:
Hb - 11 gm/dl
TLC - 12400
N/L/E/M-92/3/2/3
PCV-36.2.2
MCV-75.9.9
MCH-23.1
MCHC-30.4
RDW - CV-17.4
PLT- 2.30
NC/NC with neutrophilic leucocytosis

Phosphorous-3.6 mg/dl
Serum ca+2 - 9.2 mg/dl
Serum creatinine- 0.9

LFT:

Tb - 1.71
Db- 0.50
SGOT(AST) - 41
SGPT(ALT) - 38
ALP-250
Tp-5.4
Albumin-2.98
A/G - 1.23

SERUM ELECTROLYTES:
Na+ - 141
K+ - 4.3
Cl - - 97

ECG- on 25 .03. 22

Chest Xray:

25.03.2022

26.03.2022

ORTHO REFERAL(28.03.2022)

Lateral view of abdominal X-ray:

Xray of abdomen and pelvis:-

X Ray of pelvis and hip joint:

2D ECHO:

USG:

At the time of admission:25.03.2022

At present:31.03.2022

DIAGNOSIS: COPD with RIGHT HEART FAILURE and OSTEOPOROtic fracture of lumbar spine at level L2

TREATMENT:31.03.2022

Nebulisation with Dorolin, Butecort - 6th hourly

Inj Lasix 40mg IV BD (8am-4pm)

(Check B.P before giving lasix)

Tab Hydralazine 12.5mg PO/BD

Tab Ecosporin AV/75/20mgPO/OD

Tab Ultracet 1/2 tab QID

Intermittent CPAP for 4 hours

(With gap of 2hrs during feeds)

Vitals monitoring every hourly

Inj Zolendronic acid 4mg IV STAT

SOAP UPDATES
27/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NON TENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

SOAP UPDATES
28/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

SOAP UPDATES
29/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:116bpm
BP:100/60 mm of hg
RR-18cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

SOAP UPDATES
30/3/22

S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased

 
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

SOAP UPDATES

31-03-22

S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased

 
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P:

Nebulisation with Dorolin, Butecort - 6th hourly
Inj Lasix 40mg IV BD (8am-4pm)
(Check B.P before giving lasix)
Tab Hydralazine 12.5mg PO/BD
Tab Ecosporin AV/75/20mgPO/OD
Tab Ultracet 1/2 tab QID
Intermittent CPAP for 4 hours (With gap of 2hrs during feeds)
Vitals monitoring every hourly
Inj Zolendronic acid 4mg IV STAT