67 year old male with COPD with right heart failure

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E.Laharika 

Roll no: 29

• 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 PRESENTATION :

A 67 year old male , farmer by occupation, came with chief complaints of:

Pedal edema since 6 months 

SOB grade 2 since 2 months 

Low back ache since 2 months 

HOPI:

patient was apparently asymptomatic 2 years back then he developed shortness of breath on exertion, associated with dry cough for which he went to hospital, given medication for shortness of breath.He used to take medication   (inhalers)whenever he had shortness of breath.

 Bilateral pedal edema since 6 months,which was insidious in onset and gradually progressive. It is pitting time.

From the last 2 months shortness of breath which was of NYHA grade 2  progressed to grade 3 associated with PND. Patient complain of low back ache since 2 months which was insidious in onset gradually progressive .There is no radiation of pain . Pain is not relieved on medication.

Since one week pain was aggravated and patient was unable to sit or stand.

PAST HISTORY:

Pt is a k/c/o  COPD and is on inhalers since 2 years 

No h/o of DM , HTN, Asthma, TB

No h/o any drug allergies 

PERSONAL HISTORY:

Diet- mixed

Sleep- adequate 

Appetite- normal 

Bowel and bladder movements- Regular 

Smoking- smoked bd for about 26 years and stopped  14 years back

Occasional alcoholic- last binge 6 months back 

FAMILY HISTORY: Not significant family history

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative 

No pallor, no icterus, no Cyanosis, no clubbing, no lymphadenopathy 

Pedal edema- present 

VITALS:

Day 1

TEMPERATURE :101F

BP.:120/80mmhg

PR.:110bpm

RR.:28/min

SPO2.:88%at room air 99%@ 5litres of 02

GRBS: 133mg/dl.

Day 2 

BP.:120/80mmhg

PR.:88bpm

RR.:22/min

SPO2.:98%at room air

GRBS: 150mg/dl.

DAY 3

BP.:110/70mmhg

PR.:86bpm

RR.:18/min

SPO2.: 98% at room air 

GRBS: 109mg/dl.

DAY 4

BP.:120/80mmhg

PR.:110bpm

RR.:22/min

SPO2.:99% at room air

GRBS: 100mg/dl.

SYSTEMIC EXAMINATION: 

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- present.

Vocal fremitus- normal on both sides

Measurements:

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Percussion:   

                

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapula

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

 Vesicular breath sounds

 Rhonchi heard.

 Decreased breath sounds.

Cardiovascular system:

JVP- raised.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Abdominal examination:

Abdomen distended, umbilicus- inverted

Soft, tenderness present

No organomegaly.

Central nervous system:

No focal neurological deficit.

  

INVESTIGATIONS:

Ph-7.4

Pco2- 43.3 

Po2-97.4

So2-95

Hco3-26.7

On 4 ltrs o2

BGT-A positive 

RBS- 132 mg/dl

Blood urea- 50mg/dl

Hemogram:

Hb - 11 gm/dl

TLC - 12400

N/L/E/M-92/3/2/3

PCV-36.2.2

MCV-75.9.9

MCH-23.1

MCHC-30.4

RDW - CV-17.4

PLT- 2.30

NC/NC with neutrophilic leucocytosis

Phosphorous-3.6 mg/dl

Serum ca+2   - 9.2 mg/dl

Serum creatinine- 0.9

LFT:

Tb - 1.71

Db- 0.50

SGOT(AST) - 41

SGPT(ALT) - 38

ALP-250

Tp-5.4

Albumin-2.98

A/G - 1.23

SERUM ELECTROLYTES:

Na+ - 141

K+ -  4.3

Cl -  - 97

Serology - negative 

Troponin 1 - negative 

ECG:

   

2D ECHO

USG:

X ray

Diagnosis: COPD with right heart failure 

                    Low back pain  under evaluation 

TREATMENT-

1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD

  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD