55 YEARS OLD FEMALE WITH SOB SINCE 3 DAYS

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 I have 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 diagnosis and treatment plan.

COMPLAINTS OF SOB SINCE 3 DAYS 

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 3 DAYS BACK THEN DEVELOPED SHORTNESS OF BREATH, INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE ,CLASS 4 NYHA A/W PROFUSE SWEATING 

NOT A/W CHEST PAIN , PALPITATIONS

H/O DECREASED URINE OUTPUT PRESENT 

H/O ORTHOPNEA PRESENT 

PAST HISTORY -

-K/C/O DM 2 SINCE 2 YEARS 

-H/O CAD OLD ANTERIOR WALL MI UNDERWENT S/P PTCA -1DES TO LAD (2023)

-N/K/C/O HTN , THYROID , EPILEPSY,CVA , ASTHMA

Personal history:—

Diet- mixed (with non-veg predominant)

Sleep-adequate

Appetite- normal 

Bowel and bladder- decreased urine output.

Addictions- No

General examination:—

Patient is conscious coherent and cooperative,moderately built and nourished

Pallor-absent 

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema- absent 

Vitals:—

Temperature- afebrile 

Pulse rate- 102bpm

RR- 30cpm

Blood pressure-130/80 mmhg

Grbs:- 131mg/dl

SpO2:- 88% @room air&97% with 13 lts of O2

Systemic examination:—

Cardiovascular system:-

INSPECTION:-

Appears normal in shape

Apex beat is not visible

No Dilated veins, scars, sinuses

NO JVP RISE 

PALPATION:

1- All inspector findings were confirmed.

2-Trachea is central.

APEX BEAT at 5TH INTERCOSTAL SPACE IN 1 cm LATERAL TO MID CLAVICular 

No palpable murmurs (thrills)

PERCUSSION:- 

 Heart borders are normal limits 

AUSCULTATION:-

S 1; S 2 heard in ALL THE AREAS 

Respiratory system : 

BAE present

Trachea- centrally located

Shape of chest- bilaterally symmetrical and elliptical.

Percussion:— 

Auscultation :

Diffuse  coarse crepts present 

CNS:—

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

Per abdomen:- soft non tender

Bowel sounds heard.

Ultrasound:—

USG CHEST: 

IMPRESSION:

BILATERAL MILD TO MODERATE PLEURAL EFFUSION WITH UNDERLYING COLLAPSE.

2D echo:—

Chest x ray

SEROLOGY -

HCV-NON REACTIVE 

HIV-NON REACTIVE

HBSAg -NEGATIVE

ECG -

HEMOGRAM -

8/5/24

9/5/24

HS TROPONIN -I

SERUM CREATININE

8/5/24

9/5/24

BLOOD UREA -

8/5/24

9/5/24

LFT -

CUE -

Serum Electrolytes -

FBS -

ABG -

Provisional diagnosis:-

HFrEf  (43%) WITH PULMONARY EDEMA

 CAD OLD ANTERIOR WAL MI 

TYPE 2 DM 

CKD GRADE 3B 

TREATMENT -

1)INTERMITTENT CPAP

2)HEAD END ELEVATION

3)FLUID RESTRICTION <2.5lts /day 

4)SALT RESTRICTION <3 GMS /DAY

5)INJ LASIX 100MG IN 40 ML NS @5ml/hr 

6)INJ DOBUTAMINE 1Amp 

7)TAB CARVEDILOL 3.5 mg po/od

8)TAB ECOSPORIN GOLD 75/75/20 PO/0D 

9)NEB WITH IPRAVENT 6TH HOURLY ,BUDECORT 8TH HOURLY

10)VITALS MONITORING