Y4-History Taking Session -Medical Placement I – W3

Case scenario No.4 Lower Limb swelling

History Data
Personal Data:
Name: Mohanad/Safaa Male/Female patient Age: 60-Year-old
Occupation: teacher Residence: Live in Al Medina,
Setting: Patient came to OPD.
Reason of consultation (Chief Complaint):
- Worsening lower extremities swelling for 4 weeks duration

Detail Description for fulfilling the History of present illness:

- The condition started four weeks ago and got worse during the last two weeks.
- He describes it as bilateral symmetrical swelling.

Other relevant Symptoms (Pertinent positive and negative symptoms)

- His Leg swelling is associated with exertional shortness of breath and
shortness of breath when he is laying flat.
- He also reports palpitation, dizziness, but denies syncope.
- No GIT manifestations suggestive of chronic liver diseases
- No urinary manifestations

Review of Systems:

Respiratory: Denies productive cough.

CNS: Occasional headache otherwise unremarkable

Musculoskeletal System: Unremarkable

Skin: No skin rash, ecchymosis, or bleeding tendency.

Y4-History Taking Session -Medical Placement I – W3

Past medical history:

— - DM and hypertension
- No history of chronic drug intake, allergy.

Family history:
— - Patient father had weak heart.
Social history:
— - He/she live with his/her family and have a good social life.
— - He/she is a heavy cigarette smoker about 2 packs for 20 years
Patient’s perspectives
- Leg swelling annoys you at work because your feet doesn’t fit.
- You want doctor to give you any medication to improve your shortness of
breath and Leg swelling.
- You are afraid it might be something serious as one of your relatives had
similar condition that died due to this condition.
 From the history Data … What's your provisional diagnosis ? Why? (Explain
important history data supporting your hypothesis)
 From the history Data …. What's your Differential Diagnosis? (Explain defining and
discriminating features of each diagnosis?

Examination Data
General Examination:
The Patient looks dyspneic, conscious, oriented to time and place. Patient has
bilateral lower limb edema with raised JVP
Vital signs: Blood pressure 120/70 Pulse 80 Respiratory rate 25 Temp: 37 C
Local CVS Examination
Auscultation: S1, S2, S3 with systolic murmur in the apical area that is radiated to
axillary area.
Y4-History Taking Session -Medical Placement I – W3

Breath sound: Normal vesicular breath sound with bilateral basal crackles on the
base of both lungs. Other systemic examination reveals no abnormalities
Based on the history data and after obtaining the examination data…
What's your preliminary diagnosis ? Why? (Explain important examination data
that supporting your hypothesis)
Provisional Diagnosis
— Decompansated Heart failure
DD
 Nephrotic syndrome
 Liver cirrhosis
 Any cause of Hypoalbuminemia
 Lymphatic disease.
Q. What are the investigations of choice to reach a diagnosis??
 Chest X-ray PA view: Bilateral lung congestion with enlarge heart
 Echocardiogram: shows Reduced ejection fraction. (EF 25%)
 ECG: Showed LA enlargement with wide QRS

Treatment Plan
- IV diuresis
- ACEI/ARB
- BB.
- Spironolactone