Pulmonary Odema (Severe Acute Left Heart Failure) Dyspnea and wheeze is seen (Cardiac Dyspnea)

A 65 year old male patient came with shortness of breath, distension of abdomen and pedal edema 

This is an online e log book to discuss our patient de identified health data shared after taking his/her guardian signature on informed consent.here we discuss our individual patient 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 

CHIEF COMPLAINT 

A 65 year old male patient mason by occupation came to opd with complaint of SOB, distension of abdomen,and pedal edema since 1 week
HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic one year back 

March 2022 

Patient was taken to private hospital with complaint of shortness of breath,pedal edema and distension of abdomen,fever and was alcoholic 

Was diagnosed with renal failure and heart failure 
June 2,2022 

Patient again developed similar complaints and was diagnosed with anemia 

Hb 5 and 20 prbc transfusion was done 

1 week back on 15-1-2023 

Patient complained of shortness of breath which was insidious in onset progressed from Garde 2to grade 3, orthopnea ( )

Chest pain radiating to arms was relieved on medication 

Decreased urine output 

Pedal edema was present since 3months which is of pitting type and increased during standing 
HISTORY OF PAST ILLNESS 

No h/o Tb ,epilepsy,Asthma 

Has h/o DB 

HTN -7years back

FAMILY HISTORY 

No significant complaints in family history 

PERSONAL HISTORY:-

Married

Appetite- Normal

Diet - Mixed

Bowel and bladder- Regular

No known allergies 

Habits- alcohol (stopped one year back)
GENERAL EXAMINATION 

pallor-yes

Pedal edema-yes

No clubbing of fingers ,cyanosis,icterus,lymphadenopathy 

VITALS

Temperature-Afebrile

Pulse rate -78bpm

Bp-110/90mm of Hg

spo2-98%
SYSTEMIC EXAMINATION:

CVS

S1 &S2 heard

No thrills

No cardiac murmurs 



RESPIRATORY SYSTEM 

INSPECTION 

Size and shape -bilaterally symmetrical 

Position of trachea-central

Apical impulse-not seen

Chest expansion-symmetrical 



PALPATION:

Trachea- midline

Chest movements- symmetrical 

No intercoastal widening 

Measurements of chest expansion 

Right hemithorax-28cm

Left hemithorax-27cm



PERCUSSION 

No tenderness over chest wall 

No added sounds

No pleural rub
                                  Right        Left 

Supraclavicular       R               R

Infraavicular            R               R

Mammary               R.                R

Infra mammary           Dull             R

Axillary                    R               R

Infra axillary          R               R

Suprascapular           R          R

Interscapular            R               R

Infrascapular            Dull             R

AUSCULTATION 

Normal vesicular breath sounds heard

Dyspnoea,wheeze - present 

                             Right           Left 

Supraclavicular    NVBS          NVBS

Infraclavicular       NVBS         NVBS

Mammary              NVBS         NVBS

Axillary                 NVBS         NVBS

Infra Axillary         NVBS         NVBS

Suprascapular        NVBS         NVBS

Interscapular          NVBS         NVBS

Infrascapular          NVBS         NVBS

ABDOMEN

INSPECTION 

Shape of abdomen: distended

Surface of abdomen has no scars ,dilated veins , visible peristalsis 



PALPATION

Liver and spleen not palpable 



PERCUSSION 

Resonance sound is heard



AUSCULTATION 

Bowel sounds are heard



CNS

Patient is conscious 

Speech normal

No neck stiffness 

Motor and sensory system- Normal



PROVISIONAL DIAGNOSIS 

CKD secondary to diabetic nephropathy

 Diabetes mellitus 

Hypertension 

INVESTIGATIONS 
TREATMENT 

Tab lasix 40mg 

Tab Nodosis 500mg

Tab Orofer 

Tab Nicardia 10mg

Cap Bio D3

Tab carvidilol

Tab shelcal 

Salt fluid restriction 


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