A case of Heart failure with reduced ejection fraction with pneumonic effusions

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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 with collective current best evident based input. 

Mr. xyz aged 60 yrs presented with chief complaints of short of breath since 1 week and cough with sputum since 8 days

History of present of illness:

Mr. xyz was apparently asymptomatic 4 yrs back, then he developed swelling in the right leg which was insidious in onset, progressive and pitting type and was diagnosed as filariasis for no intervention has been done. He had history of trauma to the left leg 3 yrs back which was been operated and corrected the multiple fractures. Patient had history of decreased urine output since 20 days due to urethral stricture and treatment by dilation. Recently he presented with shortness of breath which is insidious in onset gradually progressive initially it was grade 2 Mmrc then grade 4 Mmrc and now after treating with Tab. lasix 40 mg Tab ecospirin 75 mg the grade returned to grade 2 Mmrc and history of productive cough mostly in the evenings which has mucoid sputum and it is scanty. History of wheezing is also present .No history of fever with chills, weight loss, nausea vomiting. There is history of Orthopnea and Paroxysmal nocturnal dyspnea 1 week. No history of chest pain presently. No history of palpitations and syncopal attacks. And recently 1 day ago he had developed pain in lt iliac fossa and then it is diagnosed as intramuscular abscess by the surgical department and is under treatment by aspiration with gram staining which is under further evaluation.

Past history:

no history of similar complaints in the past and no diabetes, hypertension, asthma, epilepsy, tb.

Personal history:

He is an elderly male who was farmer by occupation and stopped working since 15 yrs. His daily routine is: Wakes up at 6:00am in the morning and does his daily routine and refrained from his excess physical activity.

Diet: mixed 

Appetite: decreased 

Sleep : adequate

Bladder movements decreased

Bowel movements are regular

Smoking in the past 10 cigaretes per day 15 yrs ago

alcohol of 150 ml occasionally but stopped 1 yr ago

No History of food and drug allergies

Family history:

no relevant family history

General Physical Examination:

Patient is conscious< coherent, cooperative, well oriented to time, place, person.

moderately built and nourished

pallor present 

no icterus, cyanosis, clubbing, lymphadenopathy.

bilateral pedal edema grade 3

Vitals:

temperature: afebrile

heart rate: 80bpm

respiratory rate: 20cpm

Spo2: 96%

Systemic Examination:

Cardiovascular system:

Jvp is elevated which is 7-8cm of H2O

all arterial pulses are palpated with decreased rate regularly irregular rhythm

no radio-femoral and radio-radial delay.

on examination of precordium

inspection:

shape of chest is normal 

position of trachea is central

no visible pulsations seen

no engorged veins seen

no scars and sinuses present

palpation:

apex beat is palpated in 6th intercostal space 1cm away from mid-clavicular line 

no palpable thrills, no parasternal heaving

on auscultation s1 best heard at tricuspid and mitral area s2 best heard in aortic and pulmonary area

s3gallop heard at lt lower parasternal area with the bell 

no murmurs, clicks, snaps, bruits and venous humms

Clinical images:

INVESTIGATIONS 

CHEST XRAY INTERPRETATION:

PA VIEW 

THERE IS BLUNTING OF COSTO PHRENIC AND CARDIO PHRENIC ANGLE WITH MENISCUS SUGGESTIVE OF PLEURAL EFFUSION ON BOTH SIDES (RT>LT)

B/L RETICULAR OPACITIES AT THE HILUM SUGGESTIVE OF PNEUMONIA

SEEMS TO HAVE B/L LOWER LOBE COLLAPSE RT>LT

RT HEART BORDER AND LT HEART BORDER ARE WELL DEFINED WITH AND SUGGESTIVE OF INCREASED CT RATIO>0.55 SUGESSTIVE OF CARDIOMEGALY

Treatment:

Inj. Augmentin, 1.2 gm, IV, TID

Tab. Azithra, 500 mg, OD, Per oral

Tab. Pantop, 40 mg, OD, per oral

Tab. Met xl, 25 mg, OD, per oral

Tab. Montair LC, per oral

Tab. Ecospirin, 75 mg

Tab. Ultracet, per oral, QID

Tab. Lasix, 40 mg, BD

Neb. C duolin - 4th hourly

   budecort - 5th hourly

Final diagnosis:

Heart failure with reduced ejection fraction with atrial fibrillation 

b/l pneumonic effusion 

lt iliac fossa intramuscular abscess under evaluation