SECOND INTERNAL EXAMINATION
Second internal examination:
Date : 5/12/22
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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.
CASE REPORT
65year old male patient , was a farmer by occupation(stopped 6 yrs ago) , who is resident of chotuppal came to medicine OPD with,
CHEIF COMPLAINTS:
Lower abdominal pain for 7 days
Shortness of breath for 7 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 25 years back then he had a cough that was blood-stained when he was diagnosed with Tuberculosis ( by what test??) and was on ATT for 6 months after he was said that he is free from the disease.
Then 2 years back then he started having shortness of breath Grade 2 which is insidious in onset and relieved temporarily on medication ( drug - unknown; dose unknown; indication - unknown ) from then he had intermittent shortness of breath which relieved on the medication temporarily.
6 months back he again developed shortness of breath of grade 2 which is insidious in onset where he was taken to a higher center where he was prescribed a medication that he didn’t use properly and used only on the aggravation of shortness of breath.
After that 5 months back he suffered from an accident where his left tibia and left rib ( which rib???) got fractured where he was managed with POP casting for 45 days and on calcium tablets ( dose -500mg).
7 days back He also experienced diffuse pain all over the abdomen which was insidious in onset and was not radiating and relieved on temporary medication ( drug - unknown; dose unknown; indication - unknown ) character of pain (?)
NO H/O of Hematemesis, Malena, Vomiting, Nausea , bulky stools, black tarry, and clay-coloured. Jaundice, pruritus
NO H/O fever with chills
NO H/O anorexia
NO H/O orthopnea, palpitations
NO H/O frothy urine
NO H/O haematuria, oliguria
NO H/O blood transfusions
NO H/O tattoo marking
NO H/O loss of weight
He also developed shortness of breath for 7 days which was insidious in onset grade 3 which was relieved on medication ( drug unknown; dose - unknown)
There is a history of cough which is productive ( which has mucous as content scanty in quantity; white in colour; and no foreign bodies) fatigue; sweating ;
No history of palpitations
No H/O fever, or joint pains.
PAST HISTORY:
History of pulmonary TB 25 yrs back
History of hypertension since 3 years
No history of DM , asthma, epilepsy.
No history of prolonged hospital stay
No history of previous surgeries
PERSONAL HISTORY:
Appetite - Reduced since 1 year
Diet - Mixed
Bowel and Bladder - Regular
Sleep - inadequate
Addictions - stopped 20 years back, before alcohol and smoking
FAMILY HISTORY:
None of the patient’s parents, siblings, or first-degree relatives have or have had similar complaints or any significant co-morbidities.
ALLERGY HISTORY:
No allergies to any kind of food or medication.
Asthma/COPD/ CAD/ Blood transfusions
Any surgeries, drug usage, allergies.
HIGH ARCHED PALATE
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative comfortably seated/lying on the bed, well-oriented to time,place and person , moderately build and nourished
Pallor present,
No, Icterus, cyanosis, clubbing ,generalized lymphadenopathy and no pedal edema
Pulse: Rate:106, rhythm(regular)character(normal ), volume :- low
peripheral pulsations [Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis]- present
no radio radial delay
BP: 120/80 mm Hg measured on Rt Upper arm In supine position
Respiratory Rate:25 cpm
Temp: afebrile
Spo2:99
RESPIRATORY SYSTEM:
INSPECTION:
1. Shape of Chest - normal
2. Trachea position central
3. Apical Impulse - no visible
4. Movements of the chest: Respiratory rate:- 14cpm Type- abdomino thoracic type no accessory muscles involved.
5. Skin over the chest: Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.
6. All the areas appear normal.
PALPATION:
1. No local rise in Temperature and tenderness
2. All inspector findings confirmed. (Tracheal position, apex beat)
3. Expansion of the chest- equal in all planes
PERCUSSION:
Resonant all over the chest except infraxillary area
AUSCULTATION:
1. Normal breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.
GASTROINTESTINAL SYSTEM :
INSPECTION:
9 REGIONS
Shape (scaphoid)
No Distention of Abdomen
Flanks- full
Umbilicus- normal
The skin over the abdomen: (smooth)
No engorged veins, visible pulsations, or hernia orifices.
PALPATION:
No tenderness .
No hepatomegaly and splenomegaly
PERCUSSION:
Normal
AUSCULTATION:
1. Bowel Sounds - heard
CARDIOVASCULAR SYSTEM:
INSPECTION:-
Appears normal in shape
Apex beat is not visible
PALPATION:
1- All inspector findings were confirmed.
2-Trachea is central.
3-Apex Beat - diffuse
No palpable murmurs (thrills)
AUSCULTATION:-
S 1; S 2 heard in all the areas
PROVISIONAL DIAGNOSIS:
Sob (2° to past TB ?)
Pain abdomen under evaluation?
INVESTIGATIONS:
29/11/22:
30/11/22:
1/12/22:
2/12/22:
3/12/22:
4/12/22:
5/12/22:
DIAGNOSIS:
Heart failure with reduced ejection fraction EF 39%, With moderate LV dysfunction, acute GE (resolved ) , With history of pulmonary tuberculosis 25 years ago, AKI on CKD(2° to PCKD),with COPD? and rigth upper lobe collapse
TREATMENT:
1.inj lasix 40 mg iv/bd
2.tab metxl 25mg po/od
3.tab pan 40 mg po/od
4.tab Ultracet po/bd
5.tab clopitab-a po/od
6.tab atorvastatin 20 mg po/od
7.tab darolac po/tid
8.nebulization with
Duolin 12th hrly
Budecort 8th hrly
9.IVF-NS 50 ml/hr
10. O2 supplementation 4 th hrly
11. Vitals every 4th hrly
DAY 1 FOLLOW-UP:-
S:
4 Episodes of loose stools
O:
Pt is c/c/c
Afebrile
BP- 120/80mmHg
PR-76bpm
RR-20cpm
SpO2-98%
GRBS-98mg/dL
CVS-S1S2+
RS-BAE+
PA-soft, tenderness at Rt hypogastrium and left lumbar region
CNS-NFD
I/O- 1000/800ml
A
Pain abdomen with COR PULMONALE HEART FAILURE WITH MID RANGE EJECTION FRACTION with H/O PULMONARY KOCHS- 25 years back with ANEMIA under evaluation with AKI on PCKD.
P
1. HEAD END ELEVATION UPTO 30 degrees
2. INJ AUGMENTIN 1.2g IV/STAT
3. INJ PANTOP 40mg/IV/BD
4. NEBULIZATION WITH SALBUTAMOL 4 the hourly
5. INJ LASIX 20mg/IV/BD
6. INJ SPORLAC- DS po/TID
7. ORS sachets
3/12/22:
4/12/22:
S
5/12/22:
S: c/o Shortness of breath
O:
Pt is ccc
Afebrile
BP:110/70mm hg
PR:90bpm
RR:20cpm
CVS: S1 S2 heard
GIT: soft , non tender
RS: BAE+
GRBS:95 mg/dl
A:
Heart failure with resolved ejection fraction EF 39%, With moderate LV dysfunction, acute GE (resolved ) , multifocal atrial tachycardia 2° to COPD(resolved) ,With history of pulmonary tuberculosis 25 years ago, AKI on CKD(2° to PCKD),with COPD and rigth upper lobe collapse
P:
1) inj. Lasik 40mg iv /Bd/D
2)Tab . MGTXL 20mg PO/OD
3)Tab. Pan 40 PO/OD
4)Tab.Ultracet PO/OD
5)Tab. Clopitab A
6)Tab . Atrovastatin
7)Tab.Darolac
8)Neb . Duolin
Budicort
9)iv ns -50/ml/hr iv infusion
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