35 year old male with sob


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 Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .



CHIEF COMPLAINTS

A 35 year old who is painter by occupation came with chief complaints of shortness of breath and fever since 1 week. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 week back, then he developed 
• shortness of breath on exertion, since 1 week.
• high-grade fever since 1 week, more during night, relieved on medication and relapses back.
• decreased urine output since 1 week
• dragging type of pain in both legs and hands, associated with generalised weakness.
• orthopnea and PND present since 4 days

HISTORY OF PAST ILLNESS

No history of DM, HTN, TB, Epilepsy, leprosy, CAD, CVN, Asthma or any other chronic illness.
No history of previous transfusion. 

PERSONAL HISTORY

Built : Weakly nourished
Appetite : Decreased since 1 week
Diet : mixed
Sleep : Decreased since 1 week 
Bladder movements: 
Anuria since 1 day associated with burning micturition.
Bowel movements: regular
Addictions : toddy consumer in summer season.
Regular alcohol consumer, once a week.
No h/o smoking

FAMILY HISTORY

His wife was diagnosed with pulmonary TB, got admitted in hospital 1 month ago. 

GENERAL EXAMINATION

Patient was coherent, cooperative and conscious. Well orientated to time and space.
Pallor : absent
Icterus : present 
Clubbing: absent
Cyanosis : absent
Koilynochia: absent
Pedal edema : absent
Lymphadenopathy: absent.







Vitals


SYSTEMIC EXAMINATION 

Respiratory system

Inspection 
Shape and symmetry of chest : normal, symmetrical 
Trachea : central
Respiratory movements: normal
Apical impulse: seen
Skin over the chest : normal
Dysnea : present

Palpation
Trachea : central
Respiratory movements: normal
Fremitus : normal

Percussion
Normal 

Auscultation
Breath sounds: vesicular
Adventitious sounds : absent 
Vocal resonance: normal on both sides
Infrascapular crepts present 

Other systems

CNS : No facial asymmetry, all reflexes are normal.
GIT : Tenderness present in hypochondrium, umblical and right lumbar region.
Liver and sleep not palpable.
Mild ascites.
CVS : Thrills , present
S1, S2 heard
No murmers.
Raised JVP. 
Parasternal heave present 


Investigations





ECG findings : Biphasic T waves in V1 - V4
T wave inverted in II, III, avf. 


Provisional diagnosis: Right ventricular failure with PAH ? AKI ? LIVER FAILURE???

Treatment: Conservative 

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