This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan.
85 F presented to the casualty with chief complaints of
Shortness of breath, since 1 week
cough and fever since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5 months back then was diagnosed with hypertension and was on T AMLONG 5MG she was experiencing shortness of breath since 4 months which was insidious in onset and gradually progressive from grade 2 to grade 4.
2 months back she went to local hospital with c/o chest pain and breathlessness (GRADE 3) was diagnosed with atrial fibrillation with fast ventricular rate and was started on T.DIGOXIN ,
T.DILTIAZEM ,T.DABIGATRAN , T.DYTOR plus which she used for 15 days and stopped them abruptly .
Since 1 week patient has high grade
fever intermittent type relieved partially on medication not associated with chills and rigors
H/O productive cough since a week with mucoid non foul smelling and non blood tinged sputum
PAST HISTORY:
No similar complaints in the past
H/o hypertension since 5mon managed by Tab.Amlong 5mg
No H/o Diabetes, asthma, TB, epilepsy, CVA
PERSONAL HISTORY:
Decreased appetite takes mixed diet, regular bowel habits , normal micturition , no allergies
Family History
No relevant family history.
GENERAL PHYSICAL EXAMINATION:
Patient conscious coherent cooperative
Moderately built and nourished
Pallor present
B/L pitting edema present till knee
Jvp raised
No icterus, cyanosis, clubbing, lymphadenopathy
Vitals:
Temp-98.3*F
RR-20cpm
PR- 120bpm , irregular rhythm , normal volume, no radioradial delay
BP- 130/90mmhg
SPO2-75% at RA and 96% on 6lt of oxygen
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Inspection:
Upper respiratory tract:
No oral thrush, tonsillitis, deviated nasal septum.
Lower respiratory tract:
chest is bilaterally symmetrical
Trachea is in midline
Moving symmetrically with inspiration and expiration
No drooping of shoulders, supraclavicular and infraclavicular hollowing, intercostal fullness, retractions, indrawings, crowding of ribs
Palpation:
No local rise in temperature and no tenderness
Trachea is central on palpation
Apical impulse is felt in 6th intercostal space lateral to mid clavicular line
Chest movements are bilaterally symmetrical
Tactile vocal fremitus
Right Left
Supraclavicular Increased normal
Infraclavicular Increased normal
Mammary normal normal
Inframammary normal normal
Axillary. Normal normal
Infraaxillary normal normal
Suprascapular normal normal
Infrascapular normal normal
Interscapular normal normal
Percussion:
Right left
Supraclavicular Dull Resonant
Infraclavicular Dull Resonant
Mammary Resonant Resonant
Inframammary Resonant Resonant
Axillary Resonant Resonant
Infraaxillary Resonant Resonant
Suprascapular normal Resonant
Infrascapular Resonant Resonant
Interscapular Resonant. Resonant
Auscultation:
Decreased breath sounds on right side.
Fine Crepts are heard in right supra clavicular infra clavicular areas.
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves felt
Auscultation :
S1,S2 are heard
no murmurs
PER ABDOMEN:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation - Soft, non-tender no palpable spleen and liver
Percussion - dull note heard over flanks
Auscultation- normal bowel sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Higher mental function - intact
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 4/5
PROVISIONAL DIAGNOSIS:
? Community Acquired Pneumonia With heart failure preserved ejection fraction.
Investigations:
Hb= 7.2
PCV=25
TLC=17,000
RBC=3.5
PLATELET COUNT=3.7
BLOOD UREA= 49
SERUM CREATININE=0.9
SERUM Na+=132
SERUM K+=3.7
SERUM Cl-=98
PT TC= 20 sec
INR= 1.4
APTT TC=39 sec
T BILLIRUBIN= 1.15
D. BILLIRUBIN=0.33
SGPT= 23
SGOT= 26
ALK. PHOSPHATE=145
T. PROTEINS= 6.1
ALBUMIN=3.3
A/G RATIO=1.1
PUS CELLS=2-3
HIV= -ve
HBSAG=-ve
HCV=-ve
Blood C/S: No growth after 24hrs of aerobic culture.
Sputum C/S: Normal oropharyngeal flora grown.
Urine C/S: No growth of pathogenic organisms.
2D ECHO
No Regional Wall Motion Abnormality (RWMA) , mild LVH,
moderate MR, AR, TR ;
EF =54%,
IVC - 2.15cm dilated, noncollapsing,
Dilated RA, LA,RV, IVC
IVC post lasix
CT CHEST -
fibrotic changes in right upper lobe, fibro-bronchiectatic changes in right middle lobe (post infectious sequel)
mild cardiomegaly
CT SCAN images showing aortic calcification and tracheal calcification
TREATMENT:
INJ LASIX 40mg IV BD
INJ MONOCEF 1 gm IV BD
TAB DOLO 650 mg PO/TID
TAB METXL 25mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
SYP ASCORIL -LS 10ml PO TID
CPAP
Vitals monitoring 4th hrly
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