FINAL PRACTICAL LONG CASE

80 year old female with shortness of breath

K ANKITHA 

1701006090

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 available 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-centered online learning portfolio and your valuable inputs on the comment box

A 80 yr old female patient dailywage labourer by occupation was brought to casuality with 

CHIEF COMPLAINTS :-

(1)Shortness of breath since 10 days .

(2)Dry cough since 10 days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 20 yrs back then 

* she had history of giddiness and headache tried to treat herself at home for few days but symptoms didn't subsided for which she went to hospital and was diagnosed with hypertension and from then

She is on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily. 

* 6 yrs back she had history of polyuria for which she went to RMP who told her that she had uncontrolled sugars and prescribed Tab.metformin 500 mg once daily.

*3 yrs back she had history of severe pain abdomen and diagnosed with appendicitis and appendicectomy was done

*2 yrs back she had shortness of breath initially on exertion and later progressed to even at rest associated with pedal edema.

* 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest associated with cough which is not associated with expectoration.

* She also had orthopnea and paroxysmal nocturnal dyspnea.

Chest pain which is aggravating on coughing

PAST HISTORY:-

*Known case of Diabetes and hypertension.

* Underwent appendicectomy - 3 yrs back.

* Has a history of similar complaints in the past .

PERSONAL HISTORY:-

DIET-mixed

APEPTITE- Normal

BOWEL &BLADDER-Regular

SLEEP-Adequate.

ADDICTIONS- Alcohol monthly twice (2-3yrsback).

FAMILY HISTORY:-

Not significant

GENERAL EXAMINATION:-

Patient is conscious coherent cooperative well oriented to time place person.

Moderate built and moderately nourished.

Pallor Present

No cyanosis, clubbing, icterus, Lymphadenopathy,  Edema

*Vitals : 

Bp -130/80mmhg

PR -50 bpm irregularly irregular vessel wall hard

RR : 20 cpm

Spo2 : 84 on RA, 96 On 4lts O2

SYSTEMIC EXAMINATION :

*CARDIOVASCULAR SYSTEM:-

CARDIOVASCULAR SYSTEM:-

Inspection-

*Chest  is elliptical and bilaterally symmetrical.

*No Raised JVP 

*Apical impulse present.

*No engorged veins.

Palpation-

*Inspectory findings are confirmed .

*No- thrills, rubs.

*Apex beat -2cms lateral to mid clavicular line in 5th intercoastal space.

Percussion-

*Right and left heart borders normal.

Auscultation-

*S1 S2 heard 

*No murmurs.

*RESPIRATORY SYSTEM:-

Dyspnea- present

No wheeze

Breath sounds - vesicular

No Adventitious sounds 

*ABDOMINAL EXAMINATION:-

No tenderness 

No palpable liver and spleen.

Bowel sounds - present.

*CENTRAL NERVOUS SYSTEM:-

Higher mental function- intact

Normal - cranial nerves

Normal- motor and sensory system.

INVESTIGATIONS:-

PREVIOUS- 18-06-2020

04-06-2022

2D Echo :

Left Atrium dilated

Left ventricular hypertrophy

USG : 

04/6/22 : 

ECG - 07-06-2022

chest xray :

PROVISIONAL DIAGNOSIS:-

HEART FAILURE WITH PRESERVED EJECTION FRACTION

WITH CARDIOGENIC PULMONARY EDEMA.

TREATMENT:-

1)Inj. Atropine 0.5ml/iv/sos

2)Inj.pantop.40mg/iv/OD

3)Inj.lasix 40mg /iv/bd( 8:00am & 4:00pm)

4)Inj. Zofer 4mg /iv/sos

5)Tab .Ecosporin -Av 75/10mg/OD

6)Inj.CLEXANE 60mg/sc

7)Tab.OROFER-XT po/OD