Case History - 3

 This is an online E logbook 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 a series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.


CHIEF COMPLAINTS:-

A 50 y/o man who is a daily wage labourer in a nearby village came to OPD with 

1) Shortness of breath - 25 days

2) Swollen feet - 2 months 


HISTORY OF PRESENT ILLNESS :

* The patient was Asymptomatic 2 months back, then he developed Shortness of breath and Oedema aggravated to the knee in the past 20 days

* The patient stopped working since the past 25 days because of severe S.O.B - Grade 3 and weakness.

* The s.o.b aggravated in the supine position and he wakes from sleep due to s.o.b

* Pt. c/o pedal oedema on and off since 1 month which aggravated to the knees not subsiding since past 20 days.

* There is decreased Urine output since 20 days.

* Pt. c/o  Abdominal distension since 20 days.

* He went to the nearby hospital and was put on medication but the symptoms didn't subside.


HISTORY OF PAST ILLNESS :

* Patient is k/c/o Diabetes mellitus since 4yrs and is on Oral hypoglycemic agents

* Not  k/c/o Hypertension, Coronary Artery Disease, Asthma, T.B , Epilepsy

* No H/o any surgeries & blood transfusion


PERSONAL HISTORY :

Pt. Consumes a mixed diet which of vegetarian and Non vegetarian
Appetite -normal
Bowel movement- regular
Micturition - normal
No known allergies

* Pt. Consumes Alcohol  90ml 3-4 times/week -  since 20 years

* Regular smoker  1 pack/day -  20 years


FAMILY HISTORY : 

No H/o Diabetes, Hypertension, Heart Diseases in family


DRUG HISTORY :

Pt. is On OHA since 4yrs - 
No H/O Allergy to any of know drugs


General examination :

* Pt. is conscious, coherent, cooperative at the time of joining

* No pallor

* No icterus

*  No cyanosis

* No clubbing of fingers and toes

* No lymphadenopathy

* No pedal edema

* Vitals : temperature - afebrile
                Pulse - 100 /min
                B.P - 110/70 mmHg
                Respiratory rate - 22/min

Systemic examination : 

CVS

Inspection 

* No visible pulsations, engorged veins, scars, sinuses

* Chest wall is bilaterally symmetrical

Palpation

* No precordial bulge 

* JVP is normal

Percussion

* Apex beat at 6th Intercostal space axillary line

Auscultation 

* S1 and S2 heard

Respiratory system

* Chest Bilaterally symmetrical

* Trachea - Central

* Normal vesicular breath sounds heard

* No added sounds

PER ABDOMEN 

Inspection

* Abdomen is Obese

* No Visible scars present

Palpation

* abdomen is non-tender

* No palpable mass present

Auscultation

* Normal bowel sounds heard


Provisional Diagnosis :

Dilated Cardiomyopathy secondary to CAD


INVESTIGATIONS :

Hemogram :


Complete Urine examination


Serum Creatinine


ECG


Liver Function test


Chest Xray


Echcardiogram


Ultrasound abdomin :




        



Treatment:

Inj.LASIX - I.V - BD

Human Actrapid - SC 

THIAMINE  - IV

Tab.ECOSPIRINE 
















 





 


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