Heart failure
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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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem collective current best evident based input.
55 yr old male resident of miryalaguda came with
Chief complaints:
Shortness of breath since 8 days
Swelling in both legs since 5 days
History of present illness:
Patient was apparently asymptomatic 8 days back and developed Shortness of breath which was insidious in onset and gradual in progression which increases on activity decreases in sitting position (Mmrc gr2)
This was associated with swelling in the feet since 5 days which was pitting type and is gradual in progression and extended upto knees
(History of non progressive , non radiating Lower backache from past 5 years , for which he used analgesics from past 3 years every 2-3 days . )
No history of chest pain ,palpitation,sweating
No History of fever, cold, cough
No history of burning micturition, frothy urine,hematuria
No history of decreased urine output
Daily routine:
Patient is vegetable vendor by occupation, gets up at 6 in the morning,eats his breakfast which is mostly rice or chapati, goes to the market, his occupation is mostly associated in sitting posture.he has his lunch by 3 pm in the afternoon and returns home by 9 pm in the night
5 to 6 years Back he has history of severe lower back pain which has aggravated on sitting ,regression onpain killers
Past history:
not a known case of diabetes, hypertension, Tuberculosis. Epilepsy asthma
History H/O b/l inguinal hernia surgery 8 years back(8 years back on right side and 4 years later on left side)
PERCUSSION
dullness felt at axillary area on right side
AUSCULTATION
normal vesicular breath sounds heard and diminished sounds at right mammary and axillary areas,
Signs
Elevated jvp
Dependent edema
Laterally shifted cardiac Apical impulse
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