VANDANA REDDY

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

Here is a case i have seen:

A 80 year old man presented with chief problems of worsening dyspnea since 1 month and acutely aggravated pedal edema since 20 days.

He says his clinical syndrome began nearly 20 years ago when he started developing an irritating cough, which was worse in the morning and associated with mild quantities of mucoid, sticky, white colored sputum. He denies hemoptysis and pus or different colored sputum at any point.

His wife also reports late night and early morning wheezes, most often seen in cold climates.

Back then, the patient was a hard worker, tilling fields and herding cattle with great strength. He had to quit work because the patient reported that he slowly started losing that vigor and he often needed naps in the afternoon, after meals. He cannot recall having dyspnea at this point.

Over the next few years, the patient started developing dyspnea. This was exertional, associated with drenching sweats and he also said that he used to have cold hands during these episodes. The patient also reported that over the course of these symptoms, his sleep quality dwindled, often waking up frequently at night to micturate. On some occasions, he also reported that, a few hours into his sleep, he would have to get up, sit on the side of his bed and dangle his feet. These were few and far between. He denied having chest heaviness or pressure at that time.

Over the course of the next few years, he reported having troublesome joint pains, pointing to the wrists, fingers, elbows and shoulder and particularly the knees on both sides. He was operated for a TKR in 2008 here in KIMS. These pains were often worse with activity and were most often seen in the evenings. He denied having early morning stiffness.

In the next few years, the patient was starting to get incapacitated by his breathlessness, now needing to stop and catch his breath after walking a few yards. At this point he started needing 2 pillows to sleep comfortably.

He reports that his sleep quality worsened further when he had to wake up quite a few times in the night to pass urine. He still, however continued smoking, which had been a habit since a very young age of 15. Alcoholism too plagued him for nearly 40 years and he had to quit in 2008, given his worsening breathlessness.

A steadily declining functional capacity was further evident in his inability to get from seated position on the floor. The son in law told us that he had to use both his hands to get up from the floor after dinner. This was unusual to his earlier keeping. He also noted that he felt drowsy and slept much more earlier after his dinner than before. This was when his appetite was fairly intact.

His recall of events now get better, with the world in acute disarray, he remembered that his breathlessness completely disrupted his functional capacity when he couldn't even go the loo without feeling it. His appetite too was starting to fall, his weight too.

His weakness worsened and was evident when he couldn't squat anymore and had to pass stools standing and with some leaning forward at the hip.

The prompted a series of consultations, when he was told he had a lung problem and was given several courses of antibiotics over the past few months. Since the last 4 months he also started having bilateral lower limb edema which gradually ascended upwards till his knees. He denied facial puffiness or frothy urine or hematuria at any point. He also denied having fever which could be related to this syndrome.

The patient has been using a CPAP since the last 5 months after consultation with his primary care doctor.

Smoking Hx - 36 beedis a day for more than 30 years. Gradually decreased.

Alcohol Hx - 90 to 180ml a day for nearly 40 years.

On Gen examination :patient is conscious /coherent /cooperative.

No pallor, icterus, , clubbing, lymphadenopathy.

Pedal edema present,cyanosis present

Vitals :patient is afebrile, Bp :100/70mm Hg, pr:86bpm

On systemic examination:cvs :s1,s2heard,pansystolic murmur at aortic area

Rs:bae present, wheeze present, p/a: soft non tender, Cns :nfnd