A 75 OLD FEMALE WITH CHIEF COMPLAINTS OF SOB
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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 come up with diagnosis and treatment plan.
CHIEF COMPLAIN
75 year old female came with chief complaints of
Shortness of breath since 3days (grade 4) MMRC-
Orthopnoea since 3 days
HISTORY OF PRESENT ILLNESS
she is a house wife, resident of chandanapally.
Patient was apparently asymptomatic 10days back.Then developped Shortness of breath(grade2)-MMRC which progresses to (grade4)-MMRC 3days back.
Patient also have orthopnoea since 3days
She is developping fever(low grade) on and off since 1 year and subsides on taking medication
Poor stream of urine since morning
Nausea since morning
No PND
No h/o weight loss
No h/o lower abdominal pain,bleeding per vaginum
PAST HISTORY
-15 years back she developped psoriasis in nails (UL) later which had spread to overall body within 5years,for which she went to homeocare hospital and started on medication.After using medication,it subsided in few areas and even now she is on medication.
Aggrevated during winter,recent(in January,2022)-spread to overall body
N/K/C/O-HTN,DM,Asthma,TB,Thyroid disorders,CVA,CAD
FAMILY HISTORY
No similar complaints are present in family members
PERSONAL HISTORY
Diet: patient was a mixed diet consumer now she is been vegetarian since 15 yrs
Appetite-decreased since jan2022(no h/o weightloss)
Sleep-adequate
Bladder movements-poor stream of urine since morning
Bowel movements-regular(normal in colour)
GENERAL EXAMINATION AT ADMISSION
Patient is conscious, coherent and cooperative. Well oriented to time,place and person.
Moderately built and nourished
Pallor-present
Right eye
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy -absent
Edema-absent
VITALS ON ADMISSION
BP -80/50mmhg
PR-104bpm
TEMP-98.2°F
SPO2 -90% at RA and 100% on 5 lit O2
GRBS-162mg/dl
SYSTEMIC EXAMINATION
CVS-S1S2-+, No thrills, no murmurs
Right Parasternal heave-present
No raised JVP
R/S -BAE-+ , NVBS-heard , dyspnoea-present
Position of trachea-central
No wheeze
No adventitious sounds heard
P/A - Soft and nontender
Shape-scaphoid
No palpable mass
No free fluid
No organomegaly
Bowel sounds-heard
CNS
Patient is conscious coherent and cooperative
Speech-normal
No signs of meningeal irritation
NFND
PROVISIONAL DIAGNOSIS
HEART FAILURE WITH PRESERVED EF(EF-62.1)
WITH MODERATE TO SEVERE TR WITH PAH
WITH MODERATE MR
WITH BICYTOPENIA UNDER EVALUATION
WITH? PALMOPLANTAR PSORIASIS
INVESTIGATION
1 blood transfusion was done on 10/10/2022-PRBC(1unit)
TREATMENT
1)INJ.LASIX 40MG IV/BD
11/10/2022
S-
SOB subsided
O-
Patient is conscious coherent and cooperative
BP-90/50mmHg
PR-104bpm
TEMP-98.8°F
SPO2-96% at RA
GRBS-129 mg/dl @6AM
CVS-S1S2+,right parasternal heave present
R/S-BAE+,NVBS-heard
P/A-soft and nontender, no organomegaly
CNS-NFND
A-
HEART FAILURE WITH PRESERVED EF(EF-62.1)
WITH MODERATE TO SEVERE TR WITH PAH
WITH MODERATE MR
WITH BICYTOPENIA UNDER EVALUATION
P-
1)INJ.LASIX 40MG IV/BD
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