General Medicine - 15

A 70 YEAR OLD FEMALE CAME WITH SHORTNESS OF BREATH AND PEDAL EDEMA

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. 

CASE SHEET:

Chief complaints:

A 70 year old female , housewife by occupation, came with chief complaints of:

- Shortness of breath since 10 days

- bilateral pedal edema since 10 days

- facial puffiness since 10 days

History of present illness:

The patient was apparently asymptomatic 10 days back. She then developed Shortness of breath after waking for a few minutes ( grade IV ). She also had history of orthopnea.

 

She also developed low grade fever 10 days back which was of intermittent type which was relieved on medication with paracetamol.

10 days back she then developed bilateral pedal edemaedema, which gradually progressed upto knee which was of pitting type. Facial puffiness was present.

No history of deceased urine output, chest pain, syncope, cough or cold.

Past history:

No history of Diabetes mellitus, hypertension, coronary artery disease, epilepsy.

Personal history:

Diet: Mixed

Bowel : regular

Micturition: normal

Appetite: decreased

Habits: nil

No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:

Insignificant

GENERAL EXAMINATION:

Pallor present

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No malnutrition

No dehydration

VITALS:

Temperature: 98.9 F

Pulse: 132 beats per minute, irregular

Respiratory rate: 27 cycles per minute

Blood pressure: 120/80 mm of Hg

SPO2: 94%

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:

Shape of chest: barrel shape

Symmetry: bulge on left side

Respiratory movements: tachypnea

Rhythm: regular

Type: thoracoabdominal

Palpation:

Position of trachea: Central

Vocal fremitus: decreased on left side

Tenderness: absent

Percussion:

Hyperresonance on left side of the chest

Auscultation:

Breath sounds: vesicular

Intensity: reduced on left side

Additional sounds: coarse crepitations

Cardiovascular system:

No thrills

murmurs: systolic murmur

Cardiac sounds: S1, S2 heard

Increased JVP

Diffuse apex beat is seen on palpation

Abdomen:

Shape of abdomen: scaphoid

No tenderness

No Palpable mass

Non palpable liver

No Palpable spleen

No bruits

Bowel sounds: heard

Central Nervous System:

Conscious

Speech: normal

Investigations:

X-ray

USG:

Provisional Diagnosis:

Atrial fibrillation with heart failure