A 65 year old female patient with shortness of breath
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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. is an 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.
A 65 year old female patient came to opd with chief complaints of shortness of breath at rest since 3 days
History of present illness:
Patient was apparently asymptomatic 3 days back then she developed shortness of breath,she got sob insidious in onset,gradually progressive to current state that is grade 4.
3 days back at night she had sob insidiously ,(SBP-180)for that her grandson who works in pharmacy gave her a deriphylin ampule ,for which she got relieved and again her symptoms are exacerbated at morning,which made her to bring to the hospital.
H/o orthopnea since 3 days
H/o palpitations since 2 months
H/o weight loss from 1week
No h/o cold,cough ,fever,pnh
1 week back her second son got into RTA for which she got tensed and doesnt eat well.
H/o excessive sleep.(OSA?)
6months back she has localized unilateral swelling on left dostum of foot associated with pain relieved by Nsaid and then on to right side which was healed by hyperpigmentation (PAD?)
From 2years H/o pain in legs and sob for walking approx 1km.
Exertional sob
Yesterday, she has localized retrosternal pain at edge of the manubrium .
From 2 days she has diffuse abdominal pain .
Past HISTORY:
she has hypertension from 10 years and diabetes from 5 years for which she is using amlodipine and glimiperide.
No h/o asthma, epilepsy, tuberculosis.
No previous hospitalizations
She has left ear discharge with left ear hearing loss 3 years ago
Personal history:
She is an elderly female with two sons and one daughter confined to home ,not doing any work from past 5 years .She terminated her work as a labourer as she ageing and leg pains. In home she gets up at 6 ,do her daily routine activities and sit watch tv .Her husband died 15 years ago.As per family members,she used to get tensed for small issues.
She has Gastric problems,she uses pantop occassionally based on bloating
Family history: No significant
Treatment history: amlodipine,glimiperide,pantop
General examination
She is thin built and moderately nourished
She has visceral fat with waist to hip ratio
Pallor present
Jcterus cyanosis, clubbing lymphadenopathy, edema absent
VITALS:
On 19 march ,
Fever-97.4
Pulse rate-108, rhythm-regularly irregular,volume,character,peripheral pulses felt
Blood pressure in sitting position:
Respiratory rate :22 cpm,regular,
Grbs:220 mg/dl
Vitals chart:
SYSTEMIC EXAMINATION
CVS
on inspection
Apex beat: in 5th intercoastal space
Jvp
Palpation:
Apex beat at 5th intercoastal space at midclavicular line
Auscultation:In mitral ,tricuspid,aortic,pulmonary areas S1,s2 are heard
Rhythm regularly irregular
Lung:
Inspection: chest shape normal,
Palpation: trachea -central,sternal tenderness is noted yesterday
Percussion: dull note in inframammary and mammary regions
Auscultation: basal crepitations are heard
Per abdomen
On palpation visceral fat is more organs cannot be palpated
hearing impaired
Tuning fork tests:
Right left
256 BC>AC BC>AC
512 AC >BC BC>AC
Squint present
CNS:
MANAGEMENT
INVESTIGATIONS:
On the day of admission
CBP
Hb:10.4
TLC:14,400
Neutrophils: 83
Lymphocytes:10
Smear: normocytic normochromic Neutrophillic leukocytosis
Hba1c:7.2
RBS:332mg/dl
RFT
(17,19,20,)Urea:50,81,96
(20,22)Creatinine:2.2 ,3.2
(17) Uric acid:10.1
Calcium-10
Phosphate-4.1
Serum electrolytes 17/19/20/22
Sodium: 139, 138,137,130
Potassium:4.5,3.9,3.6,4.3
Chlorine:99,99,98,95
LFT
Totalbilirubin:1.31
DB-0.20
Ast:13
Alt :10
Alp:184
Almunin: 3
18/03 , 19/03,20/03,
Ph : 7.46 , 7.48 ,7.46
Pco2: 15.7,13.2,20
Po2:88.3,147,135
Hco3: 11.2,9.9,14.2
StHco3: 16,15.0,18.0
Interpreation: Respiratory alkalosis,high anion gap metabolic acidosis with metabolic alkalosis.
Echo shows global hypokinesia
https://youtu.be/RBzRWh9Qiro
CHEST X-RAY:
Treatment:
INJ. LASIX 20 mg IV TID
2. TAB. ECOSPIRIN -AV PO / H/S
3. TAB. AMLONG 5MG PO /OD
4. Inj. HUMAN ACTRAPID S/C ACC TO SUGAR VALUE
5. TAB. PANTOP 40 MG PO /OD
6. TAB. ISOLAZINE 20 MG PO /BD
7. MONITOR BP , GRBS, INFORM SOS
8. Fluid RESTICTION ( < 1 LT /DAY)
9. SALT RESTRICTION (< 2GM/ DAY)
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