1801006148 - SHORT CASE

  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

78 year old male with farmer by occupation, resident of Annaram came with 

CHEIF COMPLAINTS:

Difficulty in breathing,pedal edema and generalised weakness since 20 days

HISTORY OF PRESENT ILLNESS:

Pt was apparently asymptomatic 3 months back, then developed Difficulty of breathing which was insidious in onset and gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations. 

Orthopnea (+)ve, PND (+)

Not h/o facial puffiness, no decreased urine output, no burning micturition

H/o fever on and off since 2 months

PAST HISTORY:

Pt was diagnosed with dengue 1 month prior

K/c/o DM since 10 years, on T. Zoryl-m2 po/bd

K/C/O serizure disorder, on T. Carbamazepine 200mg po/od

Not k/c/o HTN, CAD, asthma, CVA, TB

No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena

PERSONAL HISTORY:

Sleep adequate, appetite decreased, bowel movements decreased, bladder regular, occasional alcoholic, non smoker

GENERAL EXAMINATION:

O/e- pt is conscious, coherent, cooperative with respect to place ,time and person , moderately built and nourished 

AFEBRILE

BP- 150/80mmgHg

PR- 81 BPM

RR-24cpm

SPO2- 99% 

Severe pallor 

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

SYSTEMIC EXAMINATION:

CVS EXAMINATION:

JVP: Normal

INSPECTION:

Chest wall symmetrical

Pulsations not seen

 PALPATION:

APEX BEAT AT 5th ICS , MCL

Thrills absent

PERCUSSION:

No abnormal findings

 AUSCULTATION: 

S1, S2 heard

No murmurs 

No added sounds

RESPIRATORY SYSTEM:

normal bilateral vesicular breath sounds

CNS: 

No neurological deficits

GIT:

No tenderness 

PROVISIONAL DIAGNOSIS

Heart failure 2° severe anemia 

INVESTIGATIONS:

Complete blood picture:

Hb:7.3 

TLC : 9900

PCV:22.8

MCV:65.7

MCH:21

MCHC:32

RDW CV:21

RDW SD:50

Platelet:3.59

RBC:3.47

Reti:0.7

RBS:70mg/dl

Sr. Cre:1.2

Pot:3.1

Sr.fe:80

Stool for occult blood : positive

Hba1c:6.5

Lipid profile:

Total cholesterol:146

Triglycerides:173

Hdl:30

Ldl:90

Vldl:34.6

2d echo :

Global hypokinesia with calcified and thickened aortic valve

Chest x ray :

ECG:

CONFIRMED DIAGNOSIS:

Heart failure with reduced ejection fraction 2° anemia 

TREATMENT:

Salt restriction < 2.4g/day

TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)

TAB ZORY - M2 PO/BD

TAB ECOSPRIRIN - AV (70/20) PO/HS

TAB CARBAMAZEPINE 200mg PO/OD

BP-MONITORING 4th HRly

GRBS 6th HRly