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Short case

45 year  old male came to the OPD with

Chief complaints of:

Bilateral pedal edema since 12days

Shortness of breath since 5days 


HOPI:

Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and is of pitting type.

He also developed Shortness of breath which was initially grade 1 and progressed to grade 2 (nyha)

Associated with orthopnea

H/o loss of appetite since one week and nausea and vomitings three days back (3 episodes) non billious

No H/o- fever,burning micturation, diarrhoea decreased urine output 

No H/o cough, hemoptysis,fever,

No h/o chest pain,giddiness , palpitations, decreased urine output, syncopal attacks,

No h/o abdominal distension, jaundice  vomitings

Past history:

Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD

Treatment history 

Not significant 

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-chronic alcoholic since 10 years and Tobacco smoking since 10 years.

Family history: Not significant 

General examination:

Patient is conscious,coherent,cooperative and well oriented with time,place,person

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Bilateral pedal edema is present,Upper limb edema







Vitals:

Temperature: 98.4 degree Fahrenheit

BP-100/80mmHg

PR-104bpm

RR-21cpm

Grbs- 147mg/dl

Systemic examination:

Respiratory system:

Inspection-

Trachea-central

Chest appears b/L symmetrical and elliptical in shape 

Palpation-

Trachea central in position 

Measurements-

AP diameter-16cms 

Transverse diameter-26cms 

Percussion              

Supraclavicular - Resonant  on R&L                 

Infraclavicular -     Resonant  on R&L 

Mammary  -            Resonant  on R&L 

Axillary -                Dull on both right and left

Suprascapular -      Resonant  on R&L 

Infrascapular -         Dull on both right and left

Auscultation:

Decreased breath sounds at axillary and infrascapular region

CVS:

Inspection: 

•  Chest is  bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•. No parasternal haeve 
JVP:Raised 
•NO Visible epigastric pulsations 
• No scars or sinuses
•Apical impulse seen in left 6th 
intercostal space lateral to mid 
clavicular line


Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line

   Para sternal heave not seen

Auscultation: 
•S1 S2 heard
•No murmurs

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


CNS:

•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: 

Left heart failure ?with bilateral pleural effusion 

Investigation:

Chest X-Ray:


Hemogram:

Hemoglobin-9.3gm/dl

Total count-12,800 cells/m3

Neutrophils-95%

Lymphocytes-62%

Eosinophils-0%

PCV-29.7 vol%

RDW-14.2%
USG:
Bilateral moderate pleural effusion with collapse of underlying lobes.
ECG - 





Blood sugar-80mg/d
Serum creatinine:1.4gm/dl
Blood urea - 21 mg/dl
FINAL DIAGNOSIS-  
heart failure with pleural effusion 

Treatment

*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD

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