60/F with shortness of breath, decreased urine output, facial puffiness , b/l 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 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 inputs on the 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 COMPLAINS:
 Shortness of breath since 1 days
Decreased urine output since 3dats, anuria since morning 
Facial puffiness since 3 days 
B/l pedal edema since 1 week 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 week ago the developed bilateral pedal edema insidious in onset , progressive in nature, pitting type , extending upto knee joint. Decreased urine output since 3 days less than 500 ml /day , and anuria since morning. Facial puffiness since 3 days. Shortness of breath since 1 day, sudden onset, orthopnea present . No PND, chest pain , palpitations and giddiness . No history of fever , cough, vomiting loose stools , burning micturition. K/c/o seizure disorder since 18 years , H/o seizure episode once monthly and fall after episode, even on medication with sodium valproate 300 mg PO /OD.

PAST HISTORY
K/C/O  seizure disorder on Tab. Sodium valproate 300 mg PO/BD 
Not a K/c/o HTN/ DM/ CKD/ /TB 


PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel and bladder - regular 

Sleep - Decreased.

General examination:

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

Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

VITALS : Temp - 98.6 F

                  PR - 92bpm

                 BP - 160/60 mmhg

                RR - 36 cpm

                SPO2 - 84% onRA
                            96% on 6l o2

                GRBS - 102 mg/dl

Systemic examination: 

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        JVP raised

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Diffuse Apex beat present 

        Parasternal heave present

        Epigastric pulsations present 
        
        Palpable A2P2

Auscultation :

        S1 and S2 heard. 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No scars , sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpitation :

Abdomen is soft and tenderness present in right hypochondrium

No organomegaly.

Percussion :

Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.



CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator +.  +

Knee ++ ++

Ankle + +



Diagnosis: Heart failure with cardiogenic pulmonary edema with bilateral pleural effusion. 
Hypervolemic hyponatremia secondary to heart failure 
K/c/o seizure disorder
Anaemia ( ? Iron deficiency anaemia)

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