A CASE OF 65 YEAR OLD FEMALE

 February 22, 2203

Name: KP PRANAY 

Roll no. 81

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.

Following is the view of my case:

CHIEF COMPLAINTS:

65 year old female came to the hospital with the chief complaints of shortness of breath since 2 days.

HOPI:

Patient was apparently asymptomatic 2 years back.

2 years back patient went to the hospital in view of breathlessness (Grade-1) with no associated orthopnea, PND, sweating and was diagnosed as hypertensive and given medication (on Tab Atenolol 50mg, Tab Amlong 5mg) 

10 days back, she went to a hospital in Hyderabad with complaints of breathlessness which is gradual in onset, progressive from Grade-II to Grade-III, and was there diagnosed as Right heart failure

HRCT was done: Bilateral pleural effusion, Cardiomegaly present

Pleural tap was done showing 351 cells(predominantly lymphocytes)

No history of fever, cough, orthopnea

Past History:

Known case of Hypertension since 2 years (on regular medication on Tab Atenolol 50mg + Tab Amlong 5mg) 

The patient stopped taking the medications since Feb 3rd 2023

Now the patient was using 

Tab Telma-H(40/12.5) OD

Tab Pulmoclear(100/600) BD

Tab Nodosic 500mg

Not a known case of thyroid disorders, TB, Asthma, Epilepsy 

PERSONAL HISTORY: 

The patient is housewife by occupation 

Diet - mixed

Appetite- normal

Bowel and bladder movements regular

Sleep- adequated

Addictions- toddy/whisky in 15 days

                    chuttas 10/day, stopped 20 years ago

SURGICAL HISTORY: 

No previous surgical history

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY 

GENERAL EXAMINATION: 

Patient is Drowsy

No signs of icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals: 

BP- 130/80mmhg

PR- 102bpm

RR- 26cpm 

SpO2 - 60% @ room air

             96% @ 2 lit of O2 

Grbs- 118mg/dl

SYSTEMIC EXAMINATION: 

CVS: S1,S2 heard ,no murmurs 

RS: BAE +, crepts present in bilateral inframammary region and infraaxillary region. 

P/A: soft, non tender, 

         Bowel sound heard

Bed sore noted at the gluteal region

CNS: The patient is Drowsy

No Meningeal signs

CNS: 

                     Right. Left

Power- UL-   4/5.  4/5

              LL-  4/5.  4/5

Tone- UL-     N.       N

          LL-      N.       N

Reflexes-   B.  T.    S.  A.   K.  

Right         2+  2+  1+ +1 +1

Left-.         2+  2+    -   +1 +1

INVESTIGATIONS: (on 22/02/23)

CBP- 

Hb- 12.8

TLC- 8,600

PCV- 41.3

Platelets - 4.0

RBC- Normochromic, Normocytic blood cells

S.Electrolytes:

Na- 135

K+- 6.0

Cl- 96

Ca+2 - 9.0

S. Mg+2- 1.8

S.Creatinine- 1.1mg/dl

LFT-

CUE-

Troponin- I- 23.0

RBS- 126 mg/dl

2D- Echo:

ECG-

X-Ray-

DIAGNOSIS:

ANTERIOR WALL MI(?EVOLVED) WITH H/O RIGHT HEART FAILURE WITH MODERATE PAH

HYPERTENSION SINCE 2 YEARS

TYPE-II RESPIRATORY FAILURE 

BED SORE(GRADE-I)

TREATMENT:

On 22/02/23-

Inj Lasix 40mg IV BD 

Neb with Budecort 12th hourly 

Tab Telma 40mg PO OD

Tab Met-XL 25mg PO OD

Tab Ecosprin Gold (75/75/20) PO HS

Tab Clopidogrel  300mg PO STAT

Tab ATORVAS 80mg PO STAT