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A 55 YEAR OLD MALE WITH ANASARCA SECONDARY TO RIGHT HEART FAILURE

  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

 

    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

 

A 55y/M Barber by occupation came to OPD with Chief Complaints of :

 • Pedal Edema since 1 month

 • Abdominal Distension, Decreased Urine Output, Facial Puffiness since 1 month

 • SOB on exertion

 

 HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 month ago after which he developed 

 • Pedal edema -

  1. Started in both Lower limbs 
  2. Gradually progressive in nature & extended upto thigh and Scrotum
  3.  Pitting type

 • later patient developed Abdominal distension, facial puffiness, decreased U/O

 • He also complaints of SOB on exertion (grade 2)

 

No H/o Chest Pain, Palpitations, Orthopnea, PND, Jaundice, Hematemesis, Bleeding PR

 

 PAST HISTORY :

 • No H/o similar complaints in the past

 • Patient has swelling of left scrotum since 10y

 • Patient is not a k/c/o DM, HTN, Asthma, Epilepsy, CAD

 

 PERSONAL HISTORY :

 • Sleep Adequate

 • Appetite Normal

 • Diet Mixed

 • Bowel Regular

 • Bladder - Decreased U/O since 1 month

 • Addictions;

  1. - Chronic Alcohol Abuse since 8 years, 100 ml daily, last drank 2 days before the presentation. 
  2. - Chronic Smoker since 20 years, 1 pack of beedi for every 2 days. 

 

 FAMILY HISTORY :

No Significant Family History/of

 

GENERAL EXAMINATION :

 • Patient conscious, Coherent, Cooperative & Well Oriented to time, place, person

 • Examination was done in well light room after adequate exposure and Consent

 • O/E 

  1. Pulse 82 bpm
  2. BP 130/80 mmhg
  3. RR 22 cpm
  4. Temp Afebrile
  5. SpO2 99% on room air

 

 • No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy

     - Generalized Edema (Anasarca)

 






 LOCAL EXAMINATION :

CVS 

  • Lateral to Mid-clavicular Down and
  • line, Raised JVP Outward
  • Para Sternal Heave +nt
  • Apex 5th ICS 1cm

RS

  • Trachea Central
  • BAE +nt
  • Crepts in Right ISA, IAA

ABDOMEN

  • Distended with Flanks Full
  • Umbilicus Horizontal / Slit like
  • Non tender
  • Shifting Dullness +nt
  • No Signs of Organomegaly
  • Bowel sounds normal

CNS: NAD

 

 PROVISIONAL DIAGNOSIS : 

Anasarca Under Evaluation 

? CCF

 

 INVESTIGATIONS :

  1. CBP
  2. CUE
  3. Sr.Creat
  4. Sr.Urea
  5. LFT
  6. Urinary Protein- Creatinine Ratio
  7. USG Abdomen and Pelvis
  8. USG Scrotum
  9. CXR
  10. ECG
  11. 2D Echo

 











 DIAGNOSIS :

ANASARCA SECONDARY TO RIGHT HEART FAILURE WITH B/L HYDROCELE & B/L FANICULITIS

 

TREATMENT

  - INJ.LASIX 40mg IV/BD

Day 1 (30/06/2021

  1. INJ.OPTINEURON 1amp in 100ml NS OD
  2. FLUID RESTRICTION < 1.5l/day
  3. SALT RESTRICTION < 2gm/day
  4. Daily Abdominal Girth and Weight Monitoring
  5. I/O Charting

 

Day 2 (01/06/2021)

  1. INJ.LASIX 40mg PO/BD
  2. INJ.OPTINEURON 1amp in 100ml NS OD
  3. TAB. OFLOX-OZ 200mg PO/OD
  4. TAB. PANTOP 40mg PO/OD
  5. TAB. PCM 500mg PO/SOS
  6. TAB. TELMA 40mg PO/OD (8AM)
  7. FLUID RESTRICTION < 1.5l/day
  8. SALT RESTRICTION < 2gm/day
  9. Daily Abdominal Girth and Weight Monitoring
  10. BP/PR/TEMP 4th Hourly. 

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