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:


S
Complaints of pain abdomen

O
Pt is c/c/c
Afebrile
BP- 90/60mmHg 
PR-67bpm
RR-20 cpm
SpO2-99%
GRBS- 100mg/dL
CVS-S1S2 +
RS-BAE + 
PA-soft , tenderness at Rt hypogastrium and left lumbar region
CNS-NFD
I/O - 1400/1100ml

A

HEART FAILURE WITH REDUCED EJECTION FRACTION 
WITH MUTLIFOCAL ATRIAL FIBRILLATION (MAT) - Resolving With H/O PULMONARY KOCHS - 25years back
WITH ANEMIA under evaluation 
WITH AKI on pckd


P
1.INJ HEPARIN 500 IU /IV/QID
2.TAB CLOPIDOGREL - A (150/75) /PO/OD
3.TAB ATORVASTATIN 20mg/PO/HS
4.INJ METROGYL 100ml(500mg)/IV/TID
5.TAB MET - XL 25mg /PO/OD
6.TAB SPOROLAC -DS PO/TID
7.ORS Sachets

4/12/22:

S

Loose stools resolved

O
Pt is c/c/c
Afebrile
BP- 120/70mmHg 
PR-106bpm
RR- 24cpm
SpO2-99%
GRBS- 170mg/dL
CVS-S1S2 +
RS-BAE + 
PA-soft , No tenderness 
CNS-NFD
I/O - 2200/1150ml

A

HEART FAILURE WITH REDUCED EJECTION FRACTION 
WITH MODERATE LV DYSFUNCTION 
WITH MUTLIFOCAL ATRIAL TACHYCARDIA(Resolved)- With H/O PULMONARY KOCHS - 25years back
WITH ANEMIA under evaluation 
WITH COPD WITH RIGHT UPPER LOBE COLLAPSE
WITH AKI on pckd


P
1.INJ HEPARIN 500 IU /IV/QID
2.TAB CLOPIDOGREL - A (150/75) /PO/OD
3.TAB ATORVASTATIN 20mg/PO/HS
4.TAB MET - XL 25mg /PO/OD
5.NEBULIZATION with Duloin /Budecort
6.ORS Sachets
7.TAB DABOLAC /PO/TID


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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