HEART FAILURE WITH PRESERVED EJECTION FRACTION (54%) LUMBAR SPONDYLOSIS TYPE 2 DM HYPERTENSION

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 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. 

60YR OLD FEMALE PATIENT CAME WITH C/O LOW BACK ACHE SINCE 8 MONTHS

C/O B/L LOWER LIMB SWELLING SINCE 20 DAYS

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN SHE DEVELOPED LOW BACK ACHE OF INSIDIOUS ONSET, GRADUALLY PROGRESSIVE, RADIATING TO BOTH LOWER LIMBS, DECREASED RANGE OF MOTION, A/W TINGLING SENSATION.

H/O B/L PEDAL EDEMA EXTENDING UPTO KNEES SINCE 20 DAYS RELIEVING ON TAKING REST.

H/O SOB GRADE I MMRC

NO H/O CHEST PAIN, PALPITATIONS.

NO H/O PND, ORTHOPNEA, DECREASED URINE OUTPUT

NO H/O COUGH, COLD, FEVER

PAST HISTORY:

K/C/O DM TYPE II SINCE 1 YEAR ,ON GLIMIPERIDE 1MG PO/OD

NOT  A K/C/O CAD, CVA, SEIZURES,  TB, ASTHMA, THYROID DISORDERS

H/O JAW TUMOR

S/P- LEFT FIBULAR BONE GRAFT TO MANDIBLE

PERSONAL HISTORY:

DIET- MIXED

APPETITE- NORMAL

BOWEL AND BLADDER MOVEMENTS- REGULAR

SLEEP- ADEQUATE

ADDICTIONS- NONE

MENSTRUAL HISTORY- ATTAINED MENOPAUSE 15 YRS BACK

GENERAL EXAMINATION:

PT IS C/C/C

AFEBRILE

BP-140/80 MMHG

PR- 86BPM

RR-22CPM

SP02- 96% AT RA

GRBS- 133 MG%

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD

RS BAE +

GIT SOFT NT

CNS NFND

ORTHO REFERRAL DONE

ADVISE 

LS BRACE

TAB SHELCAL PO/OD

TAB DOLO 650 MG PO/BD


INVESTIGATION:

HEMOGRAM:

HB- 12.0 G/DL

TLC- 11000CELLS/CUMM

N/L/M/E/B- 45/45/05/05/00

PCV-36.2 VOL%

MCV-82.0 FL

PLATELET-3.32 LAKS/CUMM

SMEAR-NORMOCYTIC NORMOCHROMIC

CUE:

ALBUMIN- TRACE

 SUGARS-NIL

PUS CELLS- 2-4

EPITHELIAL CELLS- 2-3

TROPONIN I- 2.5 PG/ML

FBS- 105 MG/DL

SEROLOGY- NEGATIVE

RBS-142 MG/DL

RFT-

UREA- 25MG/DL

CREATININE-0.6 MG/DL

URIC ACID- 2.2 MG/DL

CA-10.1 MG/DL

P-3.4 MEQ/DL

NA- 137 MEQ/DL

K- 4.1 MEQ/DL

CL- 98 MEQ/DL

LFT:

TB- 0.50 MG/DL

DB-0.19 MG/DL

AST-18 IU/L

ALT-17IU/L

ALP-188IU/L

TP-7.2 G/DL

ALB-4.33 G/DL

A/G- 1.51


DIAGNOSIS:

HEART FAILURE WITH PRESERVED EJECTION FRACTION (54%)

LUMBAR SPONDYLOSIS

TYPE 2 DM

HYPERTENSION


TREATMENT:

1. T.LASIX 40 MG PO/OD

2. T. TELMA 40 MG PO/OD

3. T. GLIMIPERIDE 1 MG PO/OD

4.T. DAPAGLIFLOZINE 10 MG PO/OD

5. T. SHELCAL 500 MG PO/OD

6. T. ZERODOL-SP PO/OD

7. T. PREGABA-M PO/OD

8. T.ECOSPIRIN AV 75/20 PO HS


ADVICE AT DISCHARGE:

1. T.LASIX 40 MG PO/OD

2. T. TELMA 40 MG PO/OD

3. T. GLIMIPERIDE 1 MG PO/OD

4.T. DAPAGLIFLOZINE 10 MG PO/OD

5. T. SHELCAL 500 MG PO/OD

6. T. ZERODOL-SP PO/OD

7. T. PREGABA-M PO/OD

8. T.ECOSPIRIN AV 75/20 PO HS

9. L S BRACE

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