1701006097....long case

 


This i an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box


1701006097

A 82 yr old lady who is home maker by occupation was brought to casuality with #CHIEF COMPLAINTS :-
(1)Shortness of breath since 10 days .
(2)Dry cough since 10 days

#HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 20 yrs back then 
*she had history of giddiness and headache tried to treat herself with some home remedies  for few days to weeks but symptoms didn't subsided for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily. 

*6yrs back she had history of polyuria for which she went to RMP who told her that she had uncontrolled sugars and prescribed Tab.metformin 500 mg once daily.

*3 yrs back she had 1st episode of Shortness of breath ..initially it was only on exertion but later progressed to even at rest.... She was admitted in hospital for 1week and then discharged 
   

*2 yrs back she had similar episodes of shortness of breath initially on exertion and later progressed to even at rest associated with pedal edema 

* 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest
 *Associated with dry cough ..intermittent 
*Associated with Orthopnea and.                   Paroxysmal nocturnal Dyspnoea 
*Chest pain which increased on coughing 














#PAST HISTORY:-
*Diagnosed with Hypertension 20 yrs ago
*Diagnosed with Type 2 Diabetes mellitus      15 yrs ago
* Underwent appendicectomy - 3 yrs back.
*No other comorbidities.

#FAMILY HISTORY:-
Not significant.

#PERSONAL HISTORY:-
DIET-mixed
APEPTITE- Decreased 

BOWEL &BLADDER-Regular
SLEEP-not adequate 
ADDICTIONS- Occasional Alcohol consumption 

#GENERAL EXAMINATION:-
Patient is conscious coherent cooperative
Moderate built and moderately nourished.
Pallor present
No cyanosis, clubbing, icterus, Lymphedenopathy, pedal edema

 






















 Vitals: at the time of admission


Bp -140/70 mmhg
PR -48 bpm irregularly irregular
RR : 26 cpm

Spo2 : 84 on RA, 96 On 4lts O2


 ● VITAL SIGNS on examination








 SYSTEMIC EXAMINATION:



At the time of admission 
 
▪︎Cvs: jvp slightly elevated
Apex beat 2cms lateral to midclavicular line
S1 s2 heard
No murmurs 

RS

Dyspnea- present
No wheeze
Breath sounds - vesicular
No Adventitious sounds 



▪︎Per abd :-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present




On examination on day 2 of admission 

▪︎CARDIOVASCULAR SYSTEM:- 
        
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins





▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.

▪︎RESPIRATORY SYSTEM:-

Shape of chest-bilaterally symmetrical,elliptical
.Trachea- central
.Chest movements equal on both sides
.No kyphosis and scoliosis
.No crowding of ribs
.No scars,sinuses,visible pulsations,engorged veins
.No drooping down of shoulders
.No supraclavicular and infraclavicular hollowing
.No intercoastal indrawing



Palpation-

.All inspectors findings are confirmed
.No local rise of temperature and tenderness
.Trachea-central
.Chest movements- Equal
.Chest expansion equal
.
. Vocal Fremitus  equal

Percussion-

.resonant note


Auscultation-

.Normal vesicular breathsounds heard


▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.


On day 3 : 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.

▪︎RESPIRATORY SYSTEM:-
Slight Dyspnea present
No wheeze
Breath sounds - vesicular
No Adventitious sounds 


On day 4: 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-
>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.


▪︎RESPIRATORY SYSTEM:-
Dyspnea resolved
No wheeze
Breath sounds - vesicular
No Adventitious sounds 


CENTRAL NERVOUS SYSTEM 
Higher mental functions :-

  • Patient is conscious  ,coherent and cooperative 
  • Right handed individual
  • Memory - immediate , short term and long term memory are assessed and are normal 
  • Language and speech are normal
Cranial nerves :- intact 
Sensory system :- 
Sensation                  right                   left
 Touch                       felt                       felt
Pressure                    felt                       felt 
Pain 
-superficial              felt                       felt
-deep                         felt                       felt
Proprioception
-joint position         ✔                        ✔
-joint movement    ✔                        ✔
Temperature         felt                      felt 
Vibration                felt                      felt
Stereognosis           ✔                       ✔

Motor system 

                              Right.                  Left


BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N


TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N


POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5

Gait :- Normal
Superficial and deep reflexes are elicited
No signs ssuggestive of cerebellar dysfunction



#INVESTIGATIONS

Day 1  on 4.06.22

CBP
Hb 5.5gm/dl
TLC 7400
PLT 2.28L
microcytic hypochromic cells


LFT
TB :1.05
Db :0.35
ENZYMES: normal
TP :5.6
ALBUMIN: 3.68

RFT : unremarkable


Sr. LDH:  218 low
ESR :normal
Retic count : 0.5
Sr. Iron : 49mg/dL
Na+ : 129meq/l
cl.  -   102meq/l
k+   3.6meq/l
Mg..1.7meq/l






CXR

CXR : cardiomegaly with the features of pulmonary edema



Usg abdomen:-








Fever chart 

Ecg









2d echo:-
Left ventricle hypertrophy and Lt atria dilated






#PROVISIONAL DIAGNOSIS:-
HEART FAILURE WITH PRESERVED EJECTION FRACTION
WITH  CARDIOGENIC PULMONARY EDEMA.

#TREATMENT:-

1)Inj. Atropine 0.5ml/iv/sos
2)Inj.pantop.40mg/iv/OD
3)Inj.lasix 40mg /iv/bd( 8:00am & 4:00pm)
4)Inj. Zofer 4mg /iv/sos
5)Tab .Ecosporin -Av 75/10mg/OD
6)Inj.CLEXANE 60mg/sc
7)Tab.OROFER-XT po/OD






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