A CASE OF 85 YEAR OLD FEMALE

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:

85 year old female came to the casuality with the complaints of shortness of breath since 2 hours.

HOPI:

Patient was apparently asymptomatic 20 years back, patient developed fever with Generalized weakness along with neck pain, where she was diagnosed with Diabetes and Hypertension and started on Medication.

Her daily routine was she used to stay at home, not used to go outside and do pooja, have food and watches television.

20 days ago, she developed sudden onset of SOB, 3 hours after having dinner along with chest discomfort. SOB aggravated on lying down position, along with cough. The pateint was taken to area hospital, ECG was taken, told that it was heart stroke, where she was given a injection(?? Thrombolysis). She was taken to private hospital in Warangal. The treating doctor performed Coronary Angiography and advised for conservative management. But upon request, PTCA was done to LAD, discharged after 3 days with medication.

For 1 week, patient was fine and after that she again developed sudden onset shortness of breath,where she was taken to the same hospital and conservative management was done, but due to some issues, the attenders left the hospital and came here for further evaluation.

On 04/02/2023, she was brought to the casuality, admitted here and treated. The patient was  hemodynamically stable and discharged on 07/02/2023.

On 12/02/2023, patient again developed sudden onset SOB  which is grade 3, relieved on lying down, not associated with abdominal pain. 

Past History:

Known case of Hypertension since 20 years (on regular medication on Metoprolol 25mg)

Known case of DM since 20 years (on Metformin 500mg)

H/O CAD on medication(Ecosprin 150mg, Atorvas 40mg, Clopidogrel 75mg)

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

PERSONAL HISTORY: 

Diet - mixed

Appetite- normal

Bowel and bladder movements regular

Sleep- adequate

No addictions 

SURGICAL HISTORY: 

PTCA FOR LAD DONE ON 21/01/23

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY 

GENERAL EXAMINATION: 

Patient is C/C/C. 

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

Pallor present 

Vitals: 

BP- 120/80mmhg

PR- 110bpm

RR- 26cpm 

SpO2 - 90% @ room air

             98% @ 2 lit of O2 

Grbs- 268mg/dl

Fever charting -

SYSTEMIC EXAMINATION: 

CVS: S1,S2 heard ,no murmurs 

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

P/A: soft, non tender 

CNS: NFND 

INVESTIGATIONS: 

CBP-

Hb- 11.2

TLC- 10400

PCV- 36.6

Platelets - 2.60

RBC- Normochromic, Normocytic blood cells

S.Electrolytes:

Na- 136

K+- 3.6

Cl- 106

Ca+2 - 1.13

S.Creatinine- 1.2mg/dl

LFT-

Blood urea- 62mg/dl

Rbs- 253mg/dl

Serology - Non reactive

Chest X-ray PA view on 04/02/2023-

Chest X-ray PA view on 13/02/2023-

USG findings on 13/02/2023-

2D- Echo on 13/02/2023-

ECG on 13/02/2023-

DIAGNOSIS: 

HEART FAILURE WITH MID RANGE EJECTION FRACTION (46%)WITH CARDIOMYOPATHY WITH S/P PTCA TO LAD 20 DAYS BACK 

CAG: TRIPLE VESSEL DISEASE WITH RIGHT LL CONSOLIDATION 

? COMMUNITY ACQUIRED PNEUMONIA 

? CHRONIC KIDNEY DISEASE 

K/C/O HTN,DM SINCE 20 YEARS 

TREATMENT :

Salt restriction <2gm/day

Fluid restriction < 1.5lit/day

INJ MET-XL 25MG PO OD

INJ LASIX 40MG IV BD 

INJ HUMAN ACTRAPID INJECTION S/C ACC TO GRBS AFTER INFORMING 

T CINOD 10MG PO OD

T CLOPIDOGREL 75MG PO BD 

T ECOSPRIN 150 MG PO HS 

T ATORVAS 20MG PO OD HS