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


Comments

Post a Comment

Popular posts from this blog

Medicine internship

-
Image
1) Self reflective writing on their medical student career : Embarking on my journey as an intern in the medicine department has been a transformative experience. From the first day i.e 1/12/23 , I found myself immersed in a dynamic environment, surrounded by seasoned professionals and a wealth of medical knowledge. The hands-on nature of the internship provided me with invaluable opportunities to apply theoretical concepts to real-world patient care. Witnessing the intricacies of diagnoses, treatment plans, and the collaborative efforts of medical teams has been both challenging and rewarding. I've honed my communication skills, interacted with diverse patient populations, and navigated the fast-paced nature of healthcare delivery. Each day presents new learning opportunities, reinforcing my passion for medicine and underscoring the profound impact healthcare professionals have on individuals' lives. As I navigate through rotations, I am not just gaining clinical expertise but...
Read more

OSCE

-
Image
  Case based OSCE along with Bloom's learning levels achieved Monitoring of 70yr old female  To see for obstructive sleep apnea  Start time : 8:00 pm  End time :6:04 am Reference links : 1)  https://www.ncbi.nlm.nih.gov/books/NBK459252/ 2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5714700/
Read more

65 yr old female with chief complaints of diarrhoea, vomitings , and generalised weakness since 5 days

-
Image
  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 The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  65...
Read more