11/06/2022
Samhita Ghanathay
Hall ticket number- 1701006161
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35 year old male with shortness of breath and pedal oedema
I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.
Following is a brief about the case.
CHIEF COMPLAINTS:
A 35 year old male patient, resident of Khammam and a bar tender by occupation, came to the medicine OPD on 8/06/2022, with chief complaints of :
* Shortness of breath since 7 days
* Palpitations since 7 days
* Pedal edema since 2 days
* Cough since 2 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 1 month ago, when he started to develop shortness of breath,which was:
- insidious in onset
- gradually progressive - from no limitation in ordinary physical activity (grade 1) to slight limitation during normal activity (grade 2).
- aggrevated on lying down (Orthopnea positive)
- relieved on sitting down as well as medications.
This worsened 7 days ago when he started to develop shortness of breath at rest, which was associated with severe palpitations. There was no history of chest pain or excessive sweating.
He had 3 episodes of paroxysmal nocturnal dyspnoea - 1 about 4 days ago and 2 more the following night. He voluntarily stayed up the night following such episodes.
He developed bilateral, below knee level, pedal edema 2 days ago,which was:
- insidious in onset
- gradually progressive.
- There were no aggrevating or relieveing factors.
- No local rise of temperature and tenderness.
He also developed cough 2 days ago - which was insidious in onset and dry to start with and later progressed to cough with sputum -
- small amounts
- mucupurulent in nature
- non foul smelling
- not blood stained.
No history of
- Fever
- Vomiting
- Loose stools
He is a known alcoholic since 15 years and had an alcohol binge 2 weeks ago.
PAST HISTORY:
* No history of similar complaints in the past.
* No history of any surgery in the past.
* Not a known case of Diabetes Mellitus, Hypertension, Tuberculosis, Asthama, Epilepsy.
PERSONAL HISTORY:
* Diet - Mixed
* Appetite - Normal
* Bowel and Bladder- Regular.
* Sleep - Disturbed
* Addictions -
- Alcohol -180 ml everyday since 15 years.
- history of binge 2 weeks ago.
- Occasional smokers but continuously exposed to smoke as he works at a bar.
FAMILY HISTORY:
No history of similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Moderately built and nourished.
His consent is taken.
He is examined in a well lit room after adequate exposure.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
Truncal obesity is seen.
VITALS:
* Temperature- afebrile
* Respiratory rate - 18 cpm
* Pulse rate - 158 bpm
* Blood pressure - 110/80 mm Hg
SYSTEMIC EXAMINATION:
* CNS - Normal sensory and motor systems.
* Respiratory system - Bilateral air entry present. Normal vesicular breath sounds heard.
* CVS -
Inspection:
- Bilaterally symmetrical chest wall
- Movements - symmetrical
- Skin normal - no scars, sinuses seen.
- Apex impulse not seen.
- No visible pulsations.
- No parasternal heaving seen.
- JVP - not raised.
Palpation:
- No local rise of temperature and tenderness.
- Bilateral symmetrical chest movement.
- Apex beat - Felt in the left 6th intercostal space - about 2 cm lateral to mid clavicular line.
- Parasternal heave - absent.
- No visible pulsations.
Percussion:
- Right heart border - about 1cm to right of sternum.
- Left heart border - about 2cm lateral to mid clavicular line.
Auscultation:
- S1 and S2 heard
- murmur - absent
* Abdomen - Soft and non tender.
INVESTIGATIONS:
* Hemoglobin - 12 gm%
* TLC - 14,900 cells/cu.mm
* PCV - 37.9%
* MCV -70.9 fl
* RDW - 16.9%
* Platelet count - 2.84 lakhs/cu.mm
* RBC - 5.36 million/cu.mm
* LFT:
- Total bilirubin - 2.32 mg/dl
- Direct bilirubin - 0.02 mg/dl
- SGPT - 58 IU/L
- SGOT - 34 IU/L
- ALP - 93 IU/L
- Total protein- 6.9 g/dl
- Albumin - 4.2 g/dl
- Albumin / Globulin ratio - 1.5
* CUE: Normal
* Serum creatinine - 1mg/dl.
* Blood Urea - 22 mg/dl
*Serology
- HIV - negative
- HCV - negative
- HBsAg - negative
* Troponin I - 22.5 ng/dl
* ABG :
8/06/2022:
- pH - 7.43
- pCO2 - 26.8 mmHg
- pO2 - 76.3 mmHg
- HCO3 - 17.6 mmol/L
- St.HCO3 - 20.4 mmol/L
- O2 saturation - 93%
- Total CO2 - 35.0 mmol/L
9/06/2022:
- pH - 7.43
- pCO2 - 26.8 mmHg
- pO2 - 76.3 mmHg
- HCO3 - 17.6 mmol/L
- St.HCO3 - 20.4 mmol/L
- O2 saturation - 94%
- Total CO2 - 35.0 mmol/L
* ECG -
8/06/2022
9/06/2022
10/06/2022
11/06/2022
12/06/2022
* Echo 2D -
* Xray -
PROVISIONAL DIAGNOSIS:
Heart failure with - dialated cardiomyopathy and atrial fibrillation.
TREATMENT:
8/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV stat\BD
* Inj. THIAMINE - 200mg in 50ml normal saline IV stat\BD
9/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV\BD
* Inj LASIX 40mg\IV\TID
* Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD
* Inj. PANTOP - 40mg IV\OD
* Inj. HYDROCORT 100mg IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Neb with DUOLIN - 8th hourly
* Neb with BUDECORT - 8th hourly
10/06/2022:
* Inj. HYDROCORT 100mg IV\BD
* Inj. THIAMINE - 200mg in 50ml normal saline IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Neb with DUOLIN - 18th hourly
* Neb with BUDECORT - 18th hourly
* Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD
* Tab. CORDARONE - 150mg IV\BD
* Tab. ECOSPRIN - 180mg OD
* Tab. CLOPITAB - 75mg OD.
* Inj. CLEXANE - 60mg SC.
11/06/2022:
* Inj. AUGMENTIN - 1.2gm\IV\BD
* Tab AZITHROMYCIN 500mg PO\BD
* Tab. CORDARONE - 150mg PO\BD
* Inj. CLEXANE - 60mg SC\OD
* Tab. ECOSPRIN - 150mg PO\OD
* Tab. CLOPITAB - 75mg PO\OD.
* Tab ATORVAS - 80mg PO
* Neb with IPPAVART - 12th hourly
* Neb with BUDECORT - 12th hourly
12/06/2022:
* Tab. AUGMENTIN - 65mg PO\BD
* Tab. AZITHROMYCIN - 500mg PO\BD
* Tab. CORDARONE - PO\BD
* Inj. CLEXANE - 60mg SC\OD
* Tab. ECOSPRIN - 150mg PO\OD
* Tab. CLOPITAB - 75mg PO\OD.
* Tab ATORVAS - 50mg PO\OD
* Inj. LASIX - 40mg\IV\TID
* Tab. DILTIAZAM - 30mg PO\BD
* Inj. THIAMINE - 20mg IV\TID
* Neb with BUDECORT - 12th hourly
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