35 Year old male with shortness of breath.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

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.

CHIEF COMPLAINTS

A 35 year old who is painter by occupation came with chief complaints of 

•Shortness of  breath since 1 week.

• Fever since 1 week. 

 •Decreased urine output since 1 week

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 week back, then he developed 

• shortness of breath on exertion, since 1 week.

 Associated with orthopnea and PND present since 4 days.

• Fever since 1 week, high grade, more during night, relieved on medication,associated with dragging type of pain in both legs and hands, associated with generalised weakness.

• Decreased urine output since 1 week.

HISTORY OF PAST ILLNESS

No history of DM, HTN, TB, Epilepsy, leprosy, CAD, CVN, Asthma or any other chronic illness.

PERSONAL HISTORY

Appetite : Decreased since 1 week

Diet : mixed

Sleep : Decreased since 1 week 

Bladder movements: 

Decreased  since 1 week associated with burning micturition.

Bowel movements: regular

Addictions :  Alcohol consumer, once a week.

No h/o smoking.

FAMILY HISTORY

His wife was diagnosed with pulmonary TB, got admitted in hospital 1 month ago. 

GENERAL EXAMINATION

Patient was coherent, cooperative and conscious. Well orientated to time and space.

Pallor : absent

Icterus : present

Clubbing: absent

Cyanosis : absent

Pedal edema : absent

Lymphadenopathy: absent.

SYSTEMIC EXAMINATION:

Respiratory system

Inspection 

Shape and symmetry of chest : normal, symmetrical 

Trachea : central

Respiratory movements: normal

Apical impulse: seen

Skin over the chest : normal

Dysnea : present

Palpation

Trachea : central

Respiratory movements: normal

Fremitus : normal

Percussion:

Resonant in all areas.

Auscultation:

Breath sounds: vesicular

INFRASCAPULAR CREPTS +

Vocal resonance: normal on both sides

ABDOMINAL EXAMINATION:

Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:   Soft, non tender, no organo megaly.

 AUSCULTATION:

BOWEL SOUNDS HEARD

Cardio vascular examination:

  No visible pulsations, scars, engorged veins.  

Raised JVP.

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

  S1 S2 heard . No murmurs.

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

INVESTIGATIONS:

DIAGNOSIS:

RIGHT HEART FAILURE WITH SEVERE PAH WITH TYPE 1 RESPIRATORY FAILURE WITH EDEMATOUS BOWEL LOOPS WITH? AKI ON CKD WITH SEVERE METABOLIC ACIDOSIS SECONDARY TO ?SEPSIS.

TREATMENT:

O2 INHALATION TO MAINTAIN SATURATION ABOVE 92.

NEBULIZATION WITH DUOLIN 6TH HOURLY.

INJ PIPTAZ 2.25gm IV/TID

INJ LASIX 40 mg IV/BD

INJ THIAMINE 200MG IN 100ML NS/IV/BD

INJ OPTINEURON IN 100ML NS IV/OD OVER 30MINS

VITALS MONITORING 4TH HOURLY

STRICT I/O CHARTING.

35 year old male came with C/O fever (high grade), shortness of breath on exertion with orthopnea and PND, routine investigations were done in which 2D ECHO  shows pulmonary artery hypertension,USG abdomen shows B/L grade 1 RPD changes,edematous bowel loops in right lower abdomen,mild ascitis, Liver enzymes level are raised, serum creatinine 3.9,blood urea110,  diagnosed with  Right heart failure with severe PAH with Edematous bowel loops with Prerenal AKI with Acute hepatitis secondary to alcohol, for which symptomatic treatment was given. Today (3/11/22) serum creatinine is 1.4, patient is discharged in hemodynamically stable condition.