1801006067 long Case

This is an a 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:

A 52 year old male patient who is a vegetable vendor by occupation and resident of miryalaguda came to the casualty with chief complaints of shortness of breath since 6months.

HISTORY OF PRESENTING ILLNESS:

Patient is apparently asymptomatic 6months ago then he developed shortness of breath which is insidious in onset, intially it was for heavy work (class 1-NYHA) progressed to producing symptoms even on rest (class 4-nyha) for which he went to a local hospital in miryalguda 1month back and diagnosed to have acute kidney injury and have prescribed him bronchodilator(inhaler) which gave him temporary relief ; there are no aggrevating factors; associated with orthopnea,trepopnea, PND and nocturnal cough since 1month, decreased frequency of micturation(4 to 5 times a day usually now only for 2 times/day) since 20 days and not associated with palpitations, chest pain, syncope, fever.

Patient presented here with (class 2-nyha).

Patient has bilateral pedal edema extending upto the knee which is pitting type since 1 month which gradually progressed and he also noticed puffiness of face since 20 days.

DAILY ROUTINE:

Patient wakes up at 6 am and have a cup of tea and eats breakfast at 8am and goes to work evng he'll have cup tea and has dinner at 8pm.

Since 1 month he is not able to do his regular physical activity. He couldn't lift heavy weight and having Dyspnea with regular physical activity. 

PAST HISTORY:

No history of similar complaints in the past.

He is not a known case of Hypertension, diabetes mellitus, asthma, epilepsy, TB, CAD, CVD, thyroid abnormalities.

He has history of back pain for which he is on analgesics(nsaids??) since 1 year weekly (stopped 1 month back.)

Patient underwent hernia surgery on both the sides 6 years back on right side and 4 years back on the left side.

PERSONAL HISTORY:

Diet: Mixed

Appetite:Normal 

Sleep:Adequate

Bowel and bladder movements: regular 

Addictions: occasional alcoholic since 20 years(90ml) and gutka since 20 years.

FAMILY HISTORY:not significant.

GENERAL EXAMINATION:

Patient is conscious coherant cooperative, Moderately built and moderately nourished Pallor-present 

Icterus-absent 

Cyanosis-absent 

Clubbing-absent 

Generalised lymphadenopathy-absent

B/L Pedal edema-present 

Vitals:

Temperature- afebrile

Pulse rate-68 bpm

Respiratory rate-16cpm

Blood pressure -130/70mm of hg

SYSTEMIC EXAMINATION:

Cardiovascular system:

Inspection:

Chest wall- symmetrical

No Precordial bulge, Pectus carinatum/excavatum 

No scar, No sinuses

Apex beat felt at 6th ICS shifted laterally 2cm left to the mid clavicular line.

Jvp:Elevated 

No Parasternal heaves or thrill.

auscultation: 

    pansystolic murmur(s1- faintly heard), s2 heard

respiratory system

bae-present,normal vesicular breath sounds heard

fine crepitations on both the side

central nervous system

hmf- intact

sensory- intact

motor system-normal

cranial nerves-intact

abdominal examination

soft and non tender, no hepatomegaly, spleen is not palpable.

Clinical Images-







Provisional diagnosis:

Heart failure (HFREF) with acute kidney injury. 

Investigations:

HEMOGRAM

Haemoglobin - 12.8 gm/dl.

Total count - 9,900 cells/ column.

Neutrophils - 79%.

Lymphocytes - 09%.

Eosinophils - 02%.

Monocytes - 10%.

Basophils - 00%.

PCV- 37.4 vol%.

M C V - 87.0 fl.

M C H - 29.8 pg.

M C H C - 34.2%.

RDW-CV - 11.9%.

RDW-SD - 38.6 fl.

RBC count - 4.30 millions/cumm.

Platelet count - 3.60 lakhs/ cumm.

 SMEAR

RBC - Normocytic normochromic.

WBC - with in normal limits.

Platelets - adequate in numbet and distribution.

Hemoparasities - no hemoparasities seen.

Impression - normocytic normochromic blood picture.

Blood urea - 96 mg/dl

Serum creatinine - 4.8 mg/dl

2D Echo-

Conclusion - Moderate to sever LV dysfunction.

-Daistolic dysfunction .

Chest X-ray 


ECG




Treatment:

Inj. LASIX 40mg BD

Tab. ECOSPRIN-av 75/20mg PO

Tab.MET-xl 12.5 PO OD

Inj.THIAMINE 200mg I.v BD

Tab. PANTOP 40mg PO OD

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