FINAL PRACTICAL -SHORT CASE

 MEDICINE CASE DISCUSSION

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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

HALL TICKET NO-1701006137

12TH JUNE 2022

FINAL PRACTICAL-SHORT CASE

CHIEF COMPLAINS:

A   35 year old male patient bartender by occupation and a resident of Khammam ,came to the medicine OPD with chief complains of 

Breathlessness since 10 days

Palpatations since 7 days

Cough since 2 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 1 month ago ,then he developed shortness of breath which was insidious in onset and gradually progressive since 10 days which progressed from no limitation in ordinary activity (grade 1) to slight limitation in physical activity(grade2)(according to NYHA GRADING )

The breathlessness aggravated on lying down and was relieved on rest and with medications

This worsened 7 days ago when he started developing shortness of breath at rest which was associated with palpations.

The palpations were sudden in onset and not associated with chest pain or sweating.

The patient had 3 episodes of paroxysmal nocturnal dyspnea the previous night, due to which he had to stay up all night.

He developed bilateral pedal edema below the knees 2 days ago which was insidious in onset and gradually progressive, no aggravating and relieving factors .

The patient also complained of cough since 2 days which was insidious in onset ,which was dry at first and the progressed to cough with sputum

It was in small amount ,mucopurulent in nature ,non foul smelling ,non blood stained.

No history of fever ,vomiting ,loose stools, decreased urine output.

History of alcohol binge 1 week prior to development of palpatations.

PAST HISTORY:

No history of similar complains in the past.

Not a known case of DM ,HTN ,Epilepsy, Asthma , thyroid disorder

No previous blood transfusions.

No known surgical history.

PERSONAL HISTORY :

The patient consumes a mixed diet

Appetite is normal

Bowel and Bladder movements are regular

Sleep is disturbed since 10 days

Addictions- Alcohol intake every day since the past 15 years about 180 ml per day

He has a continuous exposure to smoke .

FAMILY HISTORY:

No similar complains in the family.

GENERAL EXAMINATION:

Examined in a well lit room with proper consent 

Patient is conscious, coherent and co-operative.

Moderately built and nourished.

Truncal obesity is present.

No pallor , icterus,  cyanosis, clubbing, lymphadenopathy and edema.

Vitals:

Temperature- Afebrile

Respiratory rate - 18cpm

Pulse rate- 165bpm

Blood pressure- 110/80mmhg

SPO2-98%

GRBS-132mg/dl post prandil

SYSTEMIC EXAMINATION:

Cardiovascular system:

INSPECTION:

Shape of the chest and symmetry: Normal - bilaterally symmetrical

Breast abnormalities: Absent 

Spine deformities: Absent 

Apical impulse:Not visible

Pulsations - Absent

Dilated veins : Absent

PALPATION:

Inspectory findings are confirmed 

Apex beat is felt in the 6 th intercoastal space , 2-3 cm from the mid clavicular line .

No parasternal heave felt.

No thrill.

PERCUSSION:

Dullness corresponding to Right Heart border is normal

Dullness corresponding to left heart border is shifted 2cm laterally

AUSCULATION:

S1 and S2 heard 

No murmurs are heard.

Central nervous system:

Conscious and coherent , normal sensory and motor responses

Respiratory system:

Normal vesicular breath sounds and bilateral entry of air

Per abdomen:  

Soft and tender .  No organomegaly.

INVESTIGATIONS:

 8th june 2022: 

serum creatinine : 1.0 mg\dl

blood urea : 22mg\dl

serum electrolytes :   Na+ - 138 mEq\L 

                                   K+ - 3.9

                                  Cl-  - 100

ABG:

Ph : 7.43

PCo2 : 26.8 mmHg

PO2 : 76.3 mmHg

HCo3: 17.6 mmol\L

St. HCo3 : 20.4 mmol\L

TCo2 : 35

O2 stat : 94.0

HEMOGRAM :

hemoglobin : 12.0 gm\dl

TLC : 14,000

PCV : 37.6

MCV : 70.9

MCH : 22.4

RDW-CV : 16.9

LIVER FUNTION TESTS : 

total bilirubin : 2.32

direct bilirubin : 0.64

SGPT : 58

SGOT : 34

9th june 2022

Ph : 7.43

PCo2 : 26.8 mmHg

PO2 : 76.3 mmHg

HCo3: 17.6 mmol\L

St. HCo3 : 20.4 mmol\L

TCo2 : 35

O2 stat : 94.0

10 th june 2022

HEMOGRAM :

Hb : 11.3

TLC : 17,100

platelets : 3.43

serum creatinine : 1.1mg\dl

11th june 2022

   HEMOGRAM :

Hb : 12.8

total count : 14,100

platelets : 3.93

RBC : 6.04 millions\cumm

XRAY:

ECG:

2D ECHO

PROVISIONAL DIAGNOSIS:

This is a case of atrial fibrillation and dilated cardiomyopathy.

TREATMENT:

 Inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min

Inj AUGMENTIN 1.2gm\IV\BD

Tab AZITHROMYCIN 500mg PO\BD

Inj HYDRODRT 100mg IV\BD

Neb with DUOLIN             @ 8th hourly

                            BUDSCORT   @ 8th hourly

Inj LASIX 40mg\IV\BD 

Inj THIAMINE 200mg in 50ml normal saline IV\TID

Tab CARDARONE 150mg 

Tab clopitab 75mg RO OD

Tab ATROVAS 80MG

Fluid restriction <1.5L per day

Salt restriction <4gm per day

Strict temperature chart 4th hourly