60 yr old gentleman with shorthness of breath and pedal oedema
A 60 YEAR OLD GENTLEMAN WITH shortness of breath and pedal oedema.
Case present: video:https://youtu.be/7rnTdy9ktQw
History of Presenting illness :
The patient was apparently asymptomatic 2 months ago, then:
- shortness of breath since 2 months on exertion and progressed to grade 4 orthopnea and paroxysmal nocturnal dyspnea.
--pedal oedema since 2 months , pitting type extending from knees to the foot, bilateral.
- generalised weakness in both lower limbs since 2 months.
Past history :
-he developed weakness in the right upper and lower limbs and lost the ability to speak since 2yrs.
He used medications for 6 months and his weakness improved but loss of speech persisted.
- he does not have any history of hypertension, diabetes mellitus, thyroid disorders, tuberculosis and epilepsy.
Personal history :
- He consumes a mixed diet,
- His appetite is normal,
- His bowel movements are irregular, constipated.
- His bladder movements are irregular, burning micturition
- He consumes alcohol daily.
Family history : is not significant
Treatment history : The patient denies taking any prior treatment.
On General Physical Examination :
- The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is poorly built and under nourished.BMI: 17.17kg/m2.
- On general examination, he can comprehend the questions asked but is unable to speak correctly. He can only make mono syllable sounds.
- His gait has short steps with large base, he cannot take a turn without any support
Vitals :
- Temperature = he is afebrile
- Pulse = 78 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
- Blood pressure = 140/100 mm of Hg and after standing for 3 minutes, it is 160/110 mm of Hg.
- Respiratory rate = 17 cycles per minute.
- JVP is elevated
- Pallor is present.
- Bilateral pedal oedema is present.
- There is no Icterus, Clubbing, Cyanosis and Generalized lymphadenopathy
CVS:
INSPECTION:
Visible apical impulse. Pericardial bulge, visible pulsations,dilated veins
PALPATION:
Apex beat felt at 6 th ICS.
Thrills- present at apex.
PURCUSSION-
AUSCULTATION-
Loud S1 present;loud P2 present;S3 Accentuating on inspiration- RVS3; Expiration - LVS3
Cervical veinous hum - present.
RESPIRATORY SYSTEM:
Dyspnea present.
Trachea appears to be central.
Shoulders are at same level.
No pectus excavatum or pectus carinatum.
No visible pulsations,dilated veins and scars.
Normal vesicular Breath sounds heard.
Bilateral fine Crepitations present in axillary,infra axillary and infrascapular areas.
P/A:
Distended abdomen
No palpable mass
Bowel sounds heard
Nervous System Examination :
On examination of the Higher Mental Functions :
- He is conscious and well oriented to date, time, season, year, place and person.
- His speech is only monosyllabic sounds. Does not have comprehensive speech.
- His short term and long term memory (when asked to repeat 3 names of objects and when asked what he had for dinner last night)
- He is able to perform basic calculations such as subtracting 7 from 100 five times (100. 93. 86, 79, 65)
- He is able to follow a 3-stage command.
- He is also able to read and obey a written command on a piece of paper ( "Close your eyes")
On examination of the Motor System :
1. Rigidity
2. Bradykinesia
3. Tremors
4. Gait and Coordination
1. Rigidity :
To elicit rigidity, I performed an activation maneuver by asking the patient to tap his hand on the thigh, while I simultaneously checked for rigidity in the wrist, elbow and the ankle.
Rigidity : Right Left
Wrist ↑↑ ↑
Elbow ↑↑ ↑
Ankle ↑↑ ↑
3. Tremors :
- Tremors not present.
- COGWHEEL RIGIDITY is not present.
- Draw a spiral test (To rule out kinetic tremors) = Normal
- Finger-to-nose test = Normal
4. Gait and Coordination :
- Gait = Reduced arm swing
- Pull Test = Normal
- Getting up from a chair with arms crossed over opposite shoulders = not able to
- Tandem Gait = Normal
- Romberg's test = not able to
Right Left
1. Muscle Bulk poor poor
2. Muscle Tone
Upper limb
Shoulder Normal Normal
Elbow Hypotonia > Hypertonia
Wrist Hypotonia > Hypertonia
Lower limb Normal Normal
3. Muscle Power
Upper Limb
Proximal 4/5 5/5
Distal 5/5 5/5
Lower Limb
Proximal 4/5 5/5
Distal 5/5 5/5
4. Reflexes
Superficial reflexes
Right Left
Corneal + +
Conjunctival + -
Abdominal + -
Plantar Flexor Flexor
Deep tendon reflexes
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 3+
Ankle 1+ 2+
Clonus Absent Absent
On examination of the Cranial Nerves :
- Cranial Nerve 1 : The patient can perceive the smell of soap
- Cranial Nerve 2 : Counting fingers at 6 meters is normal
- Cranial Nerves 3, 4 and 6 : Movements of the extra-ocular muscles, Pupillary reflex and Accommodation reflex are normal. There is no ptosis or nystagmus.
- Cranial Nerve 5 : Sensory component = Ability to perceive sensation over specific areas on the face is Normal. Motor component = Jaw jerk was elicited and the muscles of mastication are normal.
- Cranial Nerve 7 : No deviation of the angle of the mouth, no loss of nasolabial folds, he is able to puff his cheeks, grin and tightly shut his eyes.
- Cranial Nerve 8 : Rinne's test = AC > BC , Weber's test is centralized.
- Cranial Nerves 9 and 10 : Uvula is centrally placed and Gag reflex is present.
- Cranial Nerve 11 : Patient is able to shrug his shoulders against resistance. Trapezius and Sternocleidomastoid are normal.
- Cranial Nerve 12 : Patient can normally move his tongue in all directions.
On examination of the Sensory System :
Right Left
1. Pain + +
2. Crude touch + +
3. Fine touch + +
4. Vibration sense
Medial malleolus 5.7s 4.6s
Patella 9s 4.3s
Elbow 4.8s 6.4s
Wrist 5s 7s
5. Proprioception Normal Normal
6. Stereognosis Normal Normal
7. Tactile localization Normal Normal
8. Two-point discrimination Normal Normal
SUMMARY :
A 60 year old gentleman presenting with shortness of breath and pedal oedema is provisionally diagnosed with heart failure redused ejection volume secondary to coronary artery disease.
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