46 Y old male patient with B/L swelling of lower limbs since 1 month

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I have 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 diagnosis and treatment plan.

Cheif complaints:

B/L swelling of lower limbs since 1 month

Shortness of breath since 1 month

Abdominal Distension since 1 month

Cough since 3 days 

History of present illness:

Patient was apparently asymptomatic 1 year ago then he developed pedal edema and abdominal Distension for which he went to Private hospital at Devarkonda

4 months ago: again he developed abdominal Distension and tightness associated with shortness of breath. Patient also had on and off episodes of pedal edema (upto ankle only) since then 

18/11/22-c/o SOB + , Abdominal Discomfor,cough (Hrct chest done)for which he went to cardiologist for sob , 2D echo has done findings

 As they advise

28/11/22-c/o itching all over body (reduced after intake of medication),easy fatigibility. 

1 month back: swelling of both lower limbs which is pitting type initially extending upto ankle joint now  suddenly progressed upto Hip joint 

C/o sob since 1 month gradual in onset initially grade II now progressed to grade IV (aggrevated while sleeping)

C/ o increased abdominal Distension since 1 month 

C/o facial puffiness since 1 month - insidious in onset and gradually progressed to present stage

C/o cough which is sudden in onset , blood tinged 

No H/o decreased appetite, weight loss, reduced urine output

No H/o fever, pain abdomen 

Past history:

History of similar complaint 1 year ago 

K/c/o CLD 1 year ago 

Patient was diagnosed to have moderate pericardial effusion 2 months back. 

Patient was put on ATT 2 months back , now he stopped 15 days back.

N/k/c/o DM, HTN, epilepsy, CVA, CAD, thyroid disorder 

Surgical History:

Operated for? Intenstinal perforation 3 years back .

Personal History:

Appetite:normal

Diet: mixed

Bowel and bladder: regular

Habits:

Regular chronic alocholic (since 20 years : consumes - alochol 180 ml/ day and gudumba)

Smoking since 20 years ( 1 BD pack/ day)

General examination: 

Patient is conscious, coherent, cooperative

Vitals: 

PR: 96 bpm

Bp:120/90 mmHg

RR:18 CPM

Temp:99deg F

Grbs: 90 mg/ dl

Systemic examination:

Cardiovascular system 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt diffused,  

Parasternal heave felt

No thrill felt

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard

RESPIRATORY system:

B/L air entry present

Crepts+: Bilateral IMA, ISA, IAA regions

Decreased breath sound: right side 

PER ABDOMINAL EXAMINATION: 

INSPECTION: 9 regions

Distension of abdomen: distended

Flanks: full

Umbilicus: 

       Shape: everted

       Position: central

       Herniations: umbilical hernia present 

       Discharge: absent

Skin over abdomen: smooth and shiny

Vertical midline scar of past operation for ?hollow viscous perforation

No pigmentations, discolorations, sinuses, fistulae, engorged veins, visible pulsations

PALPATION: 

No local rise of temperature 

Tenderness: absent

Hepatomegaly: absent

Splenomegaly: absent

Guarding: present 

Rigidity: absent

Renal angle tenderness: absent

No rebound tenderness

No visible peristalsis 

FLUID THRILL(with extended legs): absent

PERCUSSION:

In supine position,

  Tympanic note - from xiphisternum to umbilivus

  Dull note -  below Umbilicus 

Shifting dullness: absent

Liver span : could not be detected

AUSCULTATION:

Bowel sounds: present

No bruits

CNS: HMF intact 

Investigation:

Diagnosis: 

Cor pulmonale with congestive hepatopathy

H/o ? Pulmonary koch's with TB pericarditis .

Used ATT for 2 months and stopped 15 days ago

Treatment: 

9/2/23

Fluid restrictions<1.5 lit/ day

Salt restrictions< 2 gm / day

Inj. Lasix 40 mg iv/BD

Inj. Optineuron 1 amp in 100 ml NS iv/ OD

Tab. Udiliv 300 mg po/BD

Tab. Rifagut 550 mg po/ BD

Syp lactulose 15 ml po/HS 

Syp Hepamerz 10 ml po/TID

3_4 egg whites / day 

Strict i/o charting 

Bp, pR, temp monitoring 6 th hrly

Daily weight and Abdominal girth monitoring 

8/2/23

Fluid restrictions<1.5 lit/ day

Salt restrictions< 2 gm / day

Inj. Lasix 40 mg iv/BD

Inj. Optineuron 1 amp in 100 ml NS iv/ OD

Tab. Udiliv 300 mg po/BD

Tab. Rifagut 550 mg po/ BD

Syp lactulose 15 ml po/HS 

Syp Hepamerz 10 ml po/TID

3_4 egg whites / day 

Strict i/o charting 

Bp, pR, temp monitoring 6 th hrly

Daily weight and Abdominal girth monitoring