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. Anurag ( Intern )

Roll no : 84

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 :

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

Palpitation :

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.

Palpitation:

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        ++     ++

Chest x ray -

ECG-

USG-

2D echo-

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 

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