39 YEAR OLD WITH SHORTNESS OF BREATH

Y.Navya sahithi reddy

Roll no.1701006200

2017 batch

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

A 37 year old male came to opd with c/o shortness of breath grade 4 since 3 months .

HISTORY OF PRESENTING ILLNESS:- 

Patient was apparently asymptomatic 2 years back , 

then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.

Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.

History of mild shortness of breath and chest pain 3 months back, not associated with cough, fatigue for which he went to a local hospital where patient was started on cilnidipine.

Since then complaints were on and off but did not subside.

Sob worsened since one month to grade 4 , associated with mild b/l pedal edema , non pitting, upto knees

H/o fever 20 days back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month)

Then patient came to our hospital with grade 4 sob and got admitted.

Extended personal history:-

37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.

All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion

PAST HISTORY:-

No similar complaints in the past (before 2 years) No significant medical or surgical history

Not a known case of DM, bronchial asthma, CAD, Epilepsy

FAMILY HISTORY:-

 No family history of HTN, DM, bronchial asthma, epilepsy

Addictions:-

Patient is a chronic alcoholic and chronic smoker since 15 years

Alcohol 90-150 ml per day whiskey/brandy 

1-2 beedi per day for 15 years

General examination:- 

Patient is conscious,coherent , cooperative, 

Oriented to time , place and person

Pallor present

No signs of icterus, lymphadenopathy.

Mild Pedal edema present in both legs

Temp:- 98.3 F

BP:- 190/120 mmhg

RR:- 20 cpm

PR:- 85 bpm

Systemic examination:-

CVS- S1, S2 heard,

parasternal heave grade 2, 

diffuse apex beat (right ventricular apex)

no palpable P2

Raised jvp, no thrills, no tender points

Provisional diagnosis: pleural effusion.

Questions : 

1) what are the causes for shortness of breath?

2) what are the grades in shortness of breath?

3) what is difference between transudate and exudate?