30/10/2026
THIS PATIENT DATA WAS GATHERED BY ROLL NO 2, BATCH 2023AS PART OF HER COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION
THIS IS THE CASE OF 70M SOB 1 WEEK, SWELLING OVER LEFT SIDE OF THE FACE SINCE 12 DAYS
*Age:* 70 years
*Sex:* M
*Occupation:* Previously farmer
*C/C:*
- C/o SOB - 1 wk
- Swelling over left face - 1 wk, 5 days
*HOPI:*
Pt apparently asymptomatic 2 days ago / 1 wk then developed swelling over left face sudden onset, progressive in nature, no H/o chest pain, palpitation, cough, claudication more in the morning, subsides by evening.
Then he developed SOB aggravated on walking (MMRC grade - IV) progressive in nature, gradual onset, intermittent, associated with wheezing & orthopnea
Then he developed swelling over both feet - pitting present - upto ankle 3 days
H/o cough - productive sputum white in color
No H/o fever, cold, burning micturition, allergy
*Past H/o:*
- Known case of HTN 3 yrs
- Medication - Tab Atenolol 50mg + Amlo 5mg
- No H/o DM / TB / asthma / epilepsy
*Personal H/o:*
- Diet - Mixed
- Appetite - ↓
- Sleep - disturbed
- B & B - normal, reg
- Addictions - Smoking tobacco for 30 y, stopped 10y ago
*Family H/o:* Not significant
*Gen examination:*
- Pt c/c/c well oriented to TPP O/E
- PICCLE (E) (+) 1d B/L pitting edema on both feet (ankle) 4-6mm indentation (Gr III)
*Systemic:*
- CVS - S1 S2 (+) no murmur
- CNS - NFND
- RS - Wheeze B/L (+) supramammary inspiratory
- P/A - distended
*Vitals:*
- BP - 170/86 mmHg
- PR - 75/min
- Temp - Afebrile
- SpO2 - 93% on RA
- RR - increased
A: Here is a set of Socratic questions designed to guide medical students through clinical reasoning, pathophysiology, and differential diagnosis for this case:
### 1. Localization & Anatomical Correlation (The Face & The Airway)
* The patient presents with a **sudden-onset, progressive left facial swelling** accompanied by **shortness of breath (SOB), wheezing, and orthopnea**. How do you connect a localized facial finding with respiratory distress? Could a single anatomical process explain both?
* Think about venous drainage of the head and neck. If facial swelling is accompanied by dyspnea, what vascular structure should immediately come to mind, and what conditions can cause its obstruction?
### 2. Respiratory Symptoms & Findings
* The patient has **MMRC Grade IV dyspnea** with **bilateral supramammary inspiratory wheeze**. How do you differentiate between cardiac wheezes ("cardiac asthma") and primary pulmonary wheezes (like COPD or asthma exacerbation) in an elderly patient with a 30-pack-year smoking history?
* The physical exam notes a **distended abdomen** and **grade III bilateral pitting pedal edema**. How do these findings alter your assessment of his respiratory status? Is this primarily a primary pulmonary problem or a manifestation of systemic congestion?
### 3. Cardiovascular Dynamics & History
* He has a 3-year history of **hypertension** currently managed with Atenolol and Amlodipine, yet his vitals show a BP of **170/86 mmHg**. What does this uncontrolled blood pressure in the setting of orthopnea and pedal edema suggest about his left ventricular function or volume status?
* Given his age, smoking history, and hypertension, how would you prioritize your differential diagnosis between **left heart failure leading to right heart failure (cor pulmonale / congestive heart failure)** versus an intrinsic **malignancy or superior vena cava (SVC) syndrome** causing facial swelling and respiratory compromise?
### 4. Diagnostic Workup & Next Steps
* Based on the clinical presentation (SOB, facial swelling, elevated BP, pedal edema, and wheezing), what **immediate bedside or emergency investigations** would you order to differentiate between a cardiogenic, pulmonary, or obstructive etiology?
* If you suspect fluid overload or heart failure, what specific laboratory markers and imaging modalities would you use to confirm your diagnosis?
