35YR OLD MALE WITH COMPLAINTS OF SHORTNESS OF BREATH AND PEDAL EDEMA.

Case : A 35yr old male with shortness of breath and pedal edema as chief complaints.

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. 

You can find the entire real patient clinical problem in this link here.

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

CHIEF COMPLAINTS :
. Shortness of breath since 2 weeks. 

. Swelling of both legs since 2 weeks. 

. Generalised weakness since 2 weeks. 

. Fever 1 month ago. 

COMPLAINTS IN DETAIL :

Shortness of breath :

- Grade 3 ( acc. to NYHA classification )        initially. 

- After treatment dyspnea is Grade 2.

- Associated with paroxysmal nocturnal   dyspnea. 
CAUSES -
. Cardiovascular system. 
. Respiratory system. 
. Severe anemia. 
. Psychogenic hyperventilation - anxiety        disorder. 
. Poisoning - salicylates, ethylene glycol.
. Obesity. 

Ruling out the causes :
- Respiratory system : no associated   symptoms such as cough,wheeze,   hemoptysis.
- Anemia : no pallor present. 
- No psychological issues for any anxiety   disorder. 
- No obesity present. 
- No history of poisoning. 

THE PROBABLE CAUSE OF SHORTNESS OF BREATH IS CARDIOVASCULAR SYSTEM. 

Swelling of both legs :

- Pitting type. 

- Extending upto knees. 

- Grade 2 edema. 

CAUSES - 

. Cardiovascular system. 

. Hepatic causes - cirrhosis or ascites. 

. Renal system. 

. Lymphatic cause. 

. Venous insufficiency - thrombophlebitis      or deep vein thrombosis. 

. Drugs - NSAIDS, steroids. 

Ruling out the causes :

- Hepatic causes : mild ascites present on    examination. 

- Renal system : no associated oliguria or      haematuria or facial puffiness. 

- Lymphatic cause : no history of filariasis. 

- Venous insufficiency : no associated          pain present. 

- No associated drug history. 

THE PROBABLE CAUSE OF PEDAL EDEMA IS CARDIOVASCULAR SYSTEM. 

Generalised weakness :

CAUSES - 

.Thyroid disease. 

. Anemia.

. Depression / Anxiety. 

. Congestive cardiac failure. 

. Vit. B12 deficiency. 

. Shock. 

. Hypoglycemia. 

Ruling out the causes :

- Thyroid disease???? 

    As thyroid function test not done. 

- Anemia : no pallor present. 

- No psychological issues. 

-  Vit B12 levels???? 

    Test not done. No associated tingling          or numbness present. 

-  Shock : not associated with cold,   clammy skin or feeble pulse or                 hypotension. 

- Hypoglycemia : fasting blood glucose   levels normal. 

THE PROBABLE CAUSE OF GENERALISED WEAKNESS IS CONGESTIVE CARDIAC FAILURE. 

Fever :

. Associated with chills. 

. High grade fever. 

. Treatment taken : antimalarials. 

INVESTIGATIONS DONE :

- 2D ECHO FINDINGS :

https://drive.google.com/file/d/1K9Fk66l6c79ziOF-dIYQ3vDlGbSavlr7/view?usp=drivesdk

. Ejection fraction 27%.

. All Chambers dilated. 

. Severe LV dysfunction. 

. Mild TR. 

. Severe MR.

. Trivial AR. 

- USG ABDOMEN FINDINGS :

. Grade 1 fatty liver. 

. Right moderate pleural effusion. 

. Mild ascites. 

- POST PRANDIAL BLOOD GLUCOSE           LEVELS : 205 

. Normal : 120 - 140. 

DIFFERENTIAL DIAGNOSIS :

- Dilated cardiomyopathy. 

- Heart failure with reduced ejection             fraction. 

- Associated with diabetes mellitus type   2????.