1801006117 short case
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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
CASE REPORT
55 years old male who was a daily wage labourer came to medicine opd with chief complaints;
Shortness of breath since 7 days
Decreased urinary output since 7 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7 days back then he developed shortness of breathwhich was incidious in onset and progressed from grade 2 to grade 4 agrevating on lying down position asociated with orthopnea and paroxysmal nocturnal dyspnea
History of decrease urine output since 7 days
No history of chest pain , sweating, syncope , palpitations.
No history of burning micturition, fever.
No history of cough, hemoptysis
PAST HISTORY :
History of pedal edema on and off since one year confined to ankles
Known case of hypertension since 1 year
Not a known case of diabetes, asthma , epilepsy, Tuberculosis , CAD.
No Similar complaints in the past.
Treatment history
Drug history:
Tab TELMISARTAN 40mg OD since 1 year
NSAIDS : taken since 4 years occasionally but from past 2 years taken almost daily for his leg pains
Past surgical history
No past surgical history
FAMILY HISTORY :
No significant family history
PERSONAL HISTORY :
DAILY ROUTINE :
He wakes up around 5 am in the morning and does his household chores , goes to work for 5 to 6 hrs and returns back home around lunch time 1pm and take rest for the day. He will have his dinner around 7 30 pm and goes to sleep at 9 pm. He now has stopped his daily work since a year.
Appetite - Normal
Diet - Mixed
Sleep - adequate
Bowel habits - regular
Bladder habits - decreased
Addictions - history of smoking (beedi 4 per day since he was 20 years old ), history of alcohol consumption (since 30 yrs and occasionally whisky 90 ml each time since past one year ).
GENERAL EXAMINATION :
(Consent was taken)
Patient is conscious, coherent and cooperative.
Moderately built and moderately nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing- absent
Lymphadenopathy- absent
Edema - bilateral lower limb edema , pitting type , seen in ankle region.
VITALS :
Temperature - Afebrile (98.6F)
Pulse rate - 78 bpm
Blood pressure - 130/80 mm Hg
Respiratory rate - 17 cycles per minute
SpO2 - 95%
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSYTEM:
INSPECTION:
Shape of chest - Normal
Mild raise of JVP
No Precordial bulge
No visible pulsations
Apex beat - not well appreciated on inspection
PALPATION :
Apical impulse - Shifted to 6th Intercostal space lateral to mid clavicular line.
No Parasternal heave and thrills
PERCUSSION:
Left Heart border-shifted laterally
Right Heart border- retrosternally
AUSCULTATION :
S1 , S2 heard ,no murmurs
RESPIRATORY SYSTEM:
INSPECTION :
Trachea - midline
Shape of chest - elliptical
Chest is bilaterally symmetrical and elliptical
Bilateral airway entry Present
Movements of Chest is symmetrical on both sides
Type of respiration- abdomino thoracic
No chest wall defects
Presence of a healing, crusted ulcer on the right hemithorax medial to nipple.
No sinuses / scars
PALPATION :
all inspectory findings are confirmed by Palpation
Trachea -central
Chest expansion - symmetrical
Chest circumference - 34 cms
No Tenderness over the chest
TACTILE VOCAL FREMITUS:
Right Left
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infra axillary N N
Supra scapular N N
Infra scapular N N
Inter scapular N N
PERCUSSION: dull note in Right and left infrascapular and Infraaxillary areas
AUSCULTATION:
Vocal resonance
Left Right
Supraclavicular N N
Infraclavicular N. N
Mammary N N
Inframmamry . N N
Axillary N N
Infraaxillary N N
Suprascapular N N
Infrascapular N N
Interscapular N N
Breath sounds - Crepitations heard in right and left Infraaxillary and infrascapular areas
PERABDOMINAL EXAMINATION
INSPECTION
Shape of abdomen - Normal
Umbilicus is central in position
No Scars and Sinuses
PALPATION -
No Tenderness on superficial palpation.
Temperature - Afebrile
Liver is Non Tender
Spleen is Not palpable
PERCUSSION:Tympanic note heard.
AUSCULTATION:Bowel Sounds Heard
CENTRAL NERVOUS SYSTEM
Patient is conscious coherent and cooperative
Speech is normal
No signs of meningeal irritation
Cranial nerves - intact
Sensory system normal
Motor system:
Tone - normal
Bulk - normal
Power bilaterally-5/5
Deep tendon reflexes
Biceps : ++
Triceps : ++
Supinator: ++
Knee : ++
Ankle : ++
Superficial reflexes - normal
Gait - normal
PROVISIONAL DIAGNOSIS :
Heart failure with known case of hypertension.
INVESTIGATIONS:
HEMOGRAM:
Hemoglobin - 7.7 gm/dl
Total count - 14,100 cells/cumm
Lymphocytes - 16%
PCV - 23.1 vol%
SMEAR :
RBC - Normocytic normochromic
WBC - increased count (neutrophilic leucocytosis)
Platelets - adequate
KIDNEY FUNCTION TEST:
Serum creatinine - 4.0 mg/dl
Blood urea - 95mg/dl
ABG :
PH 7.43
Pco2 - 31.6 mmHg
Po2 - 64.0 mmHg
HCO3 - 21.1 mmol/l
Urine examination :
albumin ++
sugar nil
pus cells 2-3
epithelial cells 2-3
Red blood cells 4-5
Random blood sugar - 124 mg/dl
CHEST X RAY :
Electrocardiogram :
2D ECHOCARDIOGRAPHY:
TREATMENT :
Inj. Thiamine 100mg in 50 ml NS TID
Inj. LASIX 40mg IV BD
Inj. Erythropoietin 4000IU SC Once weekly
Inj. PAN 40 mg IV OD
Tab. Nicardia Retard 10mg RT BD
Tab. Metoprolol 12.5mg RT OD
Hemodialysis
Intermittent CPAP
Allow sips of oral fluid
Monitor vitals.
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