70 year old female patient with Shortness of Breath
70 year old female patient with Shortness of Breath
26th February 2023
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70 year old female patient with Shortness of Breath
Dr. M. Prathyusha ( Intern )
Roll no : 96
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 :
70 year old female patient came to casuality with complaints of Shortness of breath since early morning
HOPI :
Patient was apparently asymptomatic 5 years ago, then she had 2 episodes of vomitings following which she was taken to the hospital and then she developed chest pain and was referred to Hyderabad where she was diagnosed with AWMI and there she underwent PTCA to LAD in 2018 and was also diagnosed as CKD immediately. CKD is being managed conservatively.
Patient again had H/O vomitings, chest pain 2 years ago and was diagnosed as IWMI but no PTCA was done as she can't tolerate the procedure and she was managed conservatively.
Patient has C/o SOB( on and off ) grade 3 , orthopnoea present , PND -ve . No H/o fever , burning micturition , pain abdomen , palpitations , vomitings , loose stools.
PAST HISTORY :
K/C/O CKD 5 years ago
K/C/O CAD 5 years ago
Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD.
PERSONAL HISTORY:
Appetite- Normal
Diet - mixed
Bowel - regular
Bladder - Normal
Addictions - None
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Pt is C,C,C
No pallor, icterus , cyanosis, clubbing, lymphadenopathy , pedal edema
Vitals -
Temp -98F
PR - 96bpm
BP - 120/70 mmhg
RR - 14cpm
SpO2 - 99% at Room air
Grbs - 158
SYSTEMIC EXAMINATION :
PER ABDOMEN :
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration
No sinuses , engorged veins, visible pulsations .
Hernial orifices are free
Palpation :
Abdomen is soft in consistency.
No organomegaly.
Liver and Spleen - Not palpable
Percussion : Tympanic note heard over the abdomen.
Auscultation:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpation:
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps. ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
INVESTIGATIONS:
CBP:
Hb - 11.7 gm/dl
TLC - 7300 cells/ cumm
RBC - 4.11 million
PLT - 2.16 lakh
RFT:
urea - 78 mg/dl
Creatinine - 2.6 mg/dl
Na - 137 mEq/L
K - 3.6 mEq/L
Cl - 98 mEq/L
LFT :
TB- 0.66 mg/dl
DB- 0.20 mg/dl
SGPT - 06 IU/L
SGOT - 15 IU/L
ALP - 153 IU/L
TP - 6.9
albumin - 4.0 gm/dl
Chest x ray -
2D echo-
PROVISIONAL DIAGNOSIS :
Heart Failure with Reduced Ejection Fraction ( EF - 40% )
K/C/O CKD since 5 years
K/C/O CAD since 5 years
S/P PTCA LAD ( on 27/01/08 )
TREATMENT :
1. Salt restriction < 2gm / day
2. Fluid restriction < 1.5 L / day
3. Inj. Lasix 40mg IV BD
4. Tab. Carvediol 3.125 mg PO BD
5. Nebulisation with Budecort 12th hourly
6. Intermittent CPAP
7. Tab. Ecosporin Gold
8. Tab. Telma 20mg PO OD
27/2/23
Admission date: 25/02/2023
ICU-bed2
Unit-6
S
Shortness of breath subsided
Chest pain subsided
No fever spikes
Stools not passed.
O
Pt is conscious , coherent , cooperative
BP-80/50mmhg
PR- 88bpm
Temp- 96.5F
RR - 26cpm
GRBS - 121mg/dl
CVS- S1,S2 heard, no murmurs
JVP not elevated
RS- BAE (+), NVBS(+)
P/A-soft, non-tender , no organomegaly
Bowel sounds(+)
CNS: NAD
A
Heart failure with reduced ejection fraction
K/C/O CAD SINCE 5 YEARS
S/F-PTCA LAD(on 27/1/18)
K/C/O CKD SINCE 5 YEARS.
P
1.Salt restriction <2gm/day
2.Fluid restriction <1.5lit/day
3.INJ.LASIX 40mg IV BD
4.TAB CARVEDIOL 3.125mg PO BD
5.NEBULISATION WITH BUDECORT 12th hourly
6.TAB ECOSPRIN 75mg
CLOPIDOGREL 75mg
ATORVAS 20mg PO OD
7.TAB TELMA 20mg PO OD
8.TAB ULTRACET 1/2 tab SOS
9.SYP CREMAFFIN 15ml PO OD H/S
10.VITAL MONITORING 2nd hourly
28/2/23
Admission date: 25/02/2023
ICU- bed no. 4
Unit-6
S
Shortness of breath present
No Chest pain
No fever spikes
C/o neck pain
Stools passed.
O
Pt is conscious , coherent , cooperative
BP-100/60mmhg
PR- 88bpm
Temp- 98.4F
RR - 28cpm
GRBS - 118mg/dl
CVS- S1,S2 heard, no murmurs
JVP not elevated
RS- BAE (+), NVBS(+)
P/A-soft, non-tender , no organomegaly
Bowel sounds(+)
CNS: NAD
A
Heart failure with reduced ejection fraction
K/C/O CAD SINCE 5 YEARS
S/F-PTCA LAD(on 27/1/18)
K/C/O CKD SINCE 5 YEARS.
P
1.Salt restriction <2gm/day
2.Fluid restriction <1.5lit/day
3.TAB.LASIX 40mg PO BD
4.TAB CARVEDIOL 3.125mg PO BD
5.NEBULISATION WITH BUDECORT 12th hourly
6.TAB ECOSPRIN 75mg
CLOPIDOGREL 75mg
ATORVAS 20mg PO OD
7.TAB ULTRACET 1/2 tab SOS
8.VITAL MONITORING 4th hourly
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