60 year old female with shortness of breath

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 N.Deepa, 9th semester

Roll no. 93

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 history

MENSTRUAL HISTORY : 

Attained menopause


GENERAL EXAMINATION : 

Patient was conscious, coherent and co-operative. Moderately built and nourished. 

No pallor 
No cyanosis
No clubbing
No icterus 
No generalized lymphadenopathy
No bilateral pedal edema


Temp - Afebrile 
B.P. - 160/ 80 mm Hg
P.R - 102 bpm
R.R - 15 cpm
GRBS - 340 mg /dl
Spo2 - 95 % @ 5 lt o2


CVS - s1 + , s2 +
RS - BAE+
CNS - NAD 
P/A - soft and non tender


INVESTIGATIONS :


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

RADIOGRAPH OF CHEST :


     




COLOUR DOPPLER : 








ECG :







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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