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60 year old female with shortness of breath
- March 18, 2022
Rambai
Roll no. 78
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.
Date of admission : 17/03/2022
CASE :
A 43 year old female is brought to the casuality with chief complaints of shortness of breath since 5 days.
HOPI :
Patient was apparently asymptomatic 5 days back. She used to do her regular previously. But later she developed grade 2 shortness of breath due to which she couldn't perform her daily activities. The shortness of breath progressed to grade 4 where she is breathless even at rest. Her attenders complained that her breathlessness worsened on lying down and improves on sitting ( orthopnea). Patient was taken to a near by hospital and an injection was given there and we don't know what the medicine was. Then she was referred to our hospital .
No history of fever, pedal edema, oliguria, cough, pnd.
PAST HISTORY :
No similar complaints in the past.
Patient is known case of hypertension since 10 years for which she is on metaprolol and amlodipine combination tablet.
She is also a diabetic since 5 years for which she is on metformin and glimiperide combination tablet.
She is not a known case of Tb, asthma, copd, epilepsy.
No previous surgical history.
PERSONAL HISTORY :
Diet - vegetarian
Appetite - normal
Sleep - disturbed sleep since sob started
Previously adequate sleep.
Bowel and bladder habits - regular
No addictions and no allergies
FAMILY HISTORY :
No significant family historyGENERAL EXAMINATION :
Patient was conscious, coherent and co-operative. Moderately built and nourished
No pallo
No cyanosi
No clubbin
No icterus
No generalized lymphadenopath
No bilateral pedal edem
Temp - Afebrile
B.P. - 160/ 80 mm H
P.R - 102 bp
R.R - 15 cp
GRBS - 340 mg /d
Spo2 - 95 % @ 5 lt o
CVS - s1 + , s
RS - BAE
CNS - NAD
P/A - soft and non tende
INVESTIGATION
CBP :
Hb - 10.4
TLC - 14400
PCV - 31.0
PLT - 3.25
RBS - 332
HBA1C - 7.2
RFT :
S.urea - 50
S. Creatinine - 2.2
Na - 139
K - 4.5
Cl - 99
LFT :
T.B - 1.31
D.B - 0.20
AST - 13
ALT - 10
ALP - 184
T.P - 6.7
Provisional diagnosis:
HFrEF (Mod. Lv dysfunction ) EF 40 %
TREATMENT:
1. INJ. LASIX 20 mg IV TID
2. TAB. ECOSPIRIN -AV PO / H/S
3. TAB. AMLONG 5MG PO /OD
4. Inj. HUMAN ACTRAPID S/C ACC TO SUGAR VALUE
5. TAB. PANTOP 40 MG PO /OD
6. TAB. ISOLAZINE 20 MG PO /BD
7. MONITOR BP , GRBS, INFORM SOS
8. Fluid RESTICTION ( < 1 LT /DAY)
9. SALT RESTRICTION (< 2GM/ DAY
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