Medicine

Hello all , I’m an intern and here is a case history of one of our patients who got admitted .

This is to complete my log book as a part of my internship duty.

A 30 year old shepherd from Gopanatlapuram presented to the OPD with complaints of Dyspnea and pedal edema since 15 days.

An able shepherd who finished schooling till Class 7 and eventually pursued his current occupation with his father, the patient had been having a fairly fulfilling life until last October when he first reported breathlessness while taking the herd atop a molehill. He remembers the event as he felt scaling this molehill was quite easy for him before but this time he felt breathless and had to rest for a while to catch up his breath. Retrospectively he says that he had a feeling of suffocation and felt relieved after a few minutes in the shade.

The patient also reported that such events have been progressive since October and that on quite a few occasions he felt heavy pounding palpitations in the middle of his chest. He says that these palpitations too were exertional and relieved with rest. He also reported that he occasionally felt very dizzy with near blacking out associated with profuse sweating. All feature subsided with rest. He never had overt LOC. Specifically, he did not have this with prolonged standing in the sun. No history of nausea or vomiting during these dizzy spells. Patient denies fatigue and thoroughly enjoyed going to work and spending time in the fields.

The patient reported that from March this year he also started having dry cough without any expectoration. He also reported nocturnal wheezing, usually at around 4 am. It was never severe to wake him up from his sleep.

With Dyspnea fast catching up and impairing his productivity, the patient stopped working for a while and visited his sister's place 15 days ago when she noticed that he was unusually becoming breathless on walking short distances. She also admitted that the patient was wheezing at around the same time he mentioned. However she noticed that it did not wake him up from his sleep.

The patient reported that he has been having pedal edema for the last 15 days. And at this point it prompted him to consult us. The patient is the youngest of 2 siblings with a very concerned and caring sister. He lives with his mother who is unemployed and depends on him. His father passhed away years ago and he says he was a chronic alcoholic.

Apart from these symptoms, he never had urinary or bowel disturbances. He has a fairly mixed diet and has a good appetite. His main concern now though is dyspnea and pedal edema limiting his quality of life.

Past history

No history of similar complaints in the past

No H/o DM ,HTN,TB,Branchial asthma

Personal history

Appetite - decreased

Sleep - inadequate

Bowel & bladder movements - regular

No addictions

No known allergies

Family history

They reported no history of similar complaints in family

General examination

Patient is concious , coherent and cooperative ,moderately built and moderately nourished

Pallor- absent

Icterus-absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy- absent

Edema- bilateral pitting type of pedal edema extending upto shins

Vitals:

Temperature: afebrile

Pulse rate: 124 bpm

RR: 20 cpm

Bp: 130/70 mmHg

SpO2:97%

Oral findings - Poor periodontal status with severe calculus, premature exfoliation of teeth, carious teeth, thick and pasty saliva, white lesion on the right side of the tongue likely candidiasis. The findings are mostly due to poor maintenance of oral hygiene owing to his mental retardation.

Other findings:He has undescended testes with very less facial hair,no axillary hair,less pubic hair belonging to tanner stage 4

Cardiac examination:

Apex beat felt in the 5 th intercoastal space within mid clavicular line,well sustained,diffuse and confined to one intercoastal space

Visible pulsations over tricuspid and mitral areas

Right ventricular heave is present

Jvp raised with prominent ‘a’ wave

S1 and s2 heard , loud p2

Holosystolic murmur of grade 3 intensity heard in pulmonary and tricuspid areas

Respiratory system:

Normal vesicular breath sounds present

B/l air entry present

P/A:

Shape of the abdomen: flat

No scars, sinuses

All quadrants moving equally with respiration

Hernial orifices intact

No local raise of temperature

No tenderness

No organomegaly

Bowel sounds heard

CNS examination:

The patient is consious , coherent, cooperative, oriented to time ,place and person

HMF are intact

Minimental score is 28

Patient is like high stepping gait

Motor system examination:

Right. Left

Bulk:UL. N. N

LL. N. N

Tone:UL. N. N

LL. N. N.

power: UL: biceps. : 4/5

Triceps. :. 4/5

Deltoid. :. 5/5

Wrist flexors. : 4/5

Wrist extensors. :. 4/5

LL: glutius. : 5/5

Iliosoas. :4/5

Quadriceps. :3/5

Gastronemius. : 4/5

Reflexes:

RT. LT

superficial.

Corneal. P P

Conjuctival. P. P

Abdominal. P. P

Cremastric. P. P

Plantor. P. P

Deep:

Biceps. +1. +1.

Triceps. +1. +1

Supinator. +1. +1

Knee jerk. +1. +1

Ankle jerk. +2. +2

Sensory examination :

Anterio lateral senses are intact on both sides

Dorsal tract senses are also intact

Tactile localisation is Normal

Two point descrimination impaired on lower limbs

Cerebellum:finger nose test : rapid

Finger - finger test : rapid

Coordination: intact

Absent meningial signs

Skull and spine are normal

Course in the hospital:

30/M presenting with features of right heart failure was diagnosed with Primary PAH. He was also found to have Hypogonadism with Tanner Stage 4 development. He also
complained of difficulty in getting up stairs and walking from 1 day before hospitalization. The patient received diuretic therapy and vasodilator therapy for heart failure and Primary PAH. He was also counseled to maintain good oral hygiene for his oral candidiasis. The patient is being discharged in a stable condition.

Investigations