1801006155 - LONG CASE




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.




CHIEF COMPLAINTS - 


85 year old female 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) and 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 abruptly.

Since 1 week patient has had high grade fever, intermittent type relieved partially on medication and 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.
K/C/O hypertension since 5 months, on tab.amlong 5mg.
No history of tuberculosis, epilepsy, diabetes, asthma or CVA.


PERSONAL HISTORY:

Decreased appetite, takes a mixed diet, regular bowel habits , normal micturition , no allergies.


FAMILY HISTORY - 

No significant 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-98.3F

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     Resonant 

Infraclavicular        Increased     Resonant

Mammary                 Resonant Resonant

Inframammary         Resonant Resonant

Axillary                      Resonant Resonant

Infraaxillary              Resonant Resonant

Suprascapular.         Resonant  Resonant 

Infrascapular            Resonant Resonant

Interscapular            Resonant Resonant



Percussion:



                                      Right          left

Supraclavicular         Dull.          Resonant 

Infraclavicular           Dull.          Resonant

Mammary               Resonant. Resonant

Inframammary      Resonant Resonant

Axillary                   Resonant Resonant

Infraaxillary            Resonant Resonant

Suprascapular        Resonant Resonant 

Infrascapular         Resonant Resonant

Interscapular         Resonant. Resonant


Auscultation - Decreased breath sounds on right side when compared to the left side.



CARDIOVASCULAR SYSTEM:

Inspection : 

Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
JVP - raised

Palpation :

Apex beat can be palpable in 6th inter costal space lateral to midclavicular line.
No thrills and parasternal heaves can be 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


Investigations:

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.

Chest X ray



ECG





2D ECHO

No Regional Wall Motion Abnormality (RWMA) , Mild LVH, moderate MR, AR, TR ; EF =54%, IVC - 2.15 , dilated, noncollapsing, Dilated RA, LA, RV, IVC.

IVC post lasix




CT CHEST -
Fibrotic changes in right upper lobe, fibrobronchiectatic changes in right middle lobe (post infectious sequel)
Mild cardiomegaly









CT Scan images showing aortic calcification and tracheal calcification





PROVISIONAL DIAGNOSIS: 

Community Acquired Pneumonia with heart failure (HFpEf).


Lab Investigations - 
   
HIV= -ve
HBSAG=-ve
HCV=-ve

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


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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