75 year old man presented with a 10 day history of worsening breathlessness and lower extremity edema



A 75 year old man presented with a 10 day history of worsening breathlessness and lower extremity edema. 

An elderly man, from the lower echelons of his community, the patient recalls that his current problem began about a decade ago when he felt breathlessness which was unusual to his then previous keeping, when he was employed as a shepherd, which he had been doing for a few decades now. On further questioning, the patient recalls chest heaviness and associated palpitations, which were exertional and pounding and associated with profuse sweating. He also reported that he often felt like he was blacking out during these episodes. A bit of rest under a good tree's shade usually resolved these symptoms. Over these years the patient got accustomed to these symptoms frequently citing aging as the causative factor. Then frequently incapacitated, he stopped work 6 years ago and went into a "retirement" of sorts. He denies a history of PND, Orthopnea, Bendopnea, Cough, overt Syncope, Expectoration, Wheezing or hemoptysis. He vehemently denies undue fatigue over these years but he reports that for the last 10 days, it got to him. He feels a sense of lassitude, when we specifically questioned for it. 

His review of systems is insignificant for any neurological or rheumatic symptoms. 

His past history is significant for profuse deep black liquidy, volumimous stools he passed for a few weeks decades ago. He was apparently evaluated for it and then started having progressively worsening rectal prolapse, which was previously reducible and has not progressed. 

His past history is also significant for jaundice about 20 years ago and a lung infection which was treated with a 1 month course of medications. 

The patient reports substance abuse disorder with nearly 5 decades of chronic beedi smoking and a local drink called 'Sara'. His diet has been self admittedly gradually decreasing since decades. His bowel and bladder have been fairly regular except for his troublesome prolapse. Sleeping had been badly affected since the last 10 days. 

The patient says he has 'seen it all' and simply hopes to be relieved of this breathlessness which can enable him to live functionally independently.


   GENERAL EXAMINATION : 

    pt is c/c/c 
   vitals :Afebrile
   bp : 110/70 mmhg 
   pr : 74 bpm 
   rr : 22 cpm 
   pallor present
   pedal edema present ,pitting type
  no icterus,cyanosis,clubbing ,lymphadenopathy

Systemic E:
CVS : Apex in the 6th ICS about 2 3 cm lateral to the MCL
https://youtu.be/m9v5e-vIQh0https://youtu.be/m9v5e-vIQh0
JVP raised 
https://youtu.be/1vGWvF-7NIkhttps://youtu.be/1vGWvF-7NIk
heaving apex
left parasternal heave +
RS dyspnea and wheeze present
      tubular breath sounds
Abdomen:  soft 
non tender 
bowel sounds +
CNS :
Reflexes.     Rt.              Lt.
Biceps     3+              3+
Triceps          3+.            3+
Supinator.     3+.            3+
Knee.              3+             3+
Ankle.             -                 -
Plantars  B/L flexors

2d echo:
https://youtu.be/fwy0wjBwwdghttps://youtu.be/f
Investigations:




Treatment
1.Fluid restriction<1.5l/day
2.Salt restriction<2g/day
3.inj.Augmentin 1.2g/iv/tid
4.inj.pantop 40mg/iv/od
5.inj.lasix40mg/iv/bd 8am -4pm if Bp>110mmhg
6.Neb with duolin 6th hrly
                    Mucomist 6th hrly
                     Budecort 12th hrly
7.inj.Thiamine 1amp in  100ml Ns/Tid

Popular posts from this blog

BIMONTHLY ASSESSMENT (JANUARY)

Image
26 year old woman with complaints of altered sensorium since 1 day,headache since 8 days,fever and vomitings since 4 days More here:  https://harikachindam7. blogspot.com/2020/12/26-year- old-female-with-complaints-of. html Case presentation  links:  https://youtu.be/fz9Jssoc-mA https://youtu.be/d4lLX04oL8s https://youtu.be/CSCxw2zp7Oc a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings? presented to casualty in a state of altered sensorium & irrelevant talk History of B/L hand small joint pains 6 yrs back Multiple joint pains 3 yrs back and diagnosed as SLE  and using treatment which she stopped 10 days ago. C/o headache since 1 month which increased in last 10 - 15 days associated with vomitings since 1 week and fever, neck pain , generalized weakness since 4 days and altered sensorium with irrelevant talk since 1 day. Anatomical localization: Headache,neckpain, fe...
Read more

22 yr old man with difficulty in walking and sitting without support since 2 months....

Image
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-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case i have seen: 22 year old man from Singaram presented with the complaints of Difficulty to walk without support since 2 month Difficulty to sit without support since 2 months He was born out of a non consanguineous marriage. His father works as a coolie at Singaram village. He is third in  birth order. He has an elder brother and sister who are married. He was delivered through normal vaginal delivery at home by a local RMP practitioner. He did not cry imm...
Read more

medicine assignment

Image
1) A 55 year old man with Recurrent Focal Seizures Detailed patient case report here:  http://ushaindurthi. blogspot.com/2020/11/55-year- old-male-with-complaints-of. html 1. What is the problem representation of this patient and what could be the anatomical site of lesion ? 55 yr old male who is k/c/o diabetic and chronic alcoholic with right upper limb weakness and involuntry movements of right upper and lower limbs, Internal capsule: pure motor strokes, ataxic hemiparesis, and clumsy hand-dysarthria.  Frontal lobe: urinary incontinence, and head and eye deviatiation Temporal lobe: It is preceeded by aura. Aura could be  sensory, emotional, cognitive, or autonomic features prior to onset of impaired awareness. Postictal confusion typically occurs. 2. Why are subcortical internal capsular infarcts more common that cortical infarcts?  Subcortical areas are supplied by penetrating branches,Occlusion of these penetrating arteries result in subcortical ...
Read more