60 year male with heart failure

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.


Vignatha 

roll no: 55

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:  

60yr old male labourer by occupation came with the complaints of cough with expectoration since 10days 

Breathless since 10days 


Patient was apparently alright 10days ago then he developed cough with expectoration since 10days, insidious in onset, gradually progressive in nature, present during night time, sputum- white in colour, scanty, non foul smelling, non blood stained 

Breathlessness since 10days, insidious onset, Gradually progressive in nature, needs to stop for breath when walking at own pace 

(grade II MMRC) Aggravated on exertion, relieved on rest

H/o chest pain while coughing, orthopnea  and PND present, sleep disturbed 

No h/o profuse sweating, pedal oedema 


Constipation present since 5years- passes stool once in 2days, hard stools, non blood stained 

Urinary hesitancy present since 5years 


No h/o similar complaints in the past 

Not a known case Type 2 DM, HTN,CVA,CAD,TB,Asthma 


Personal history -

Appetite : normal 

Diet: mixed 

Bowel and bladder: regular 

Sleep: adequate 

Addictions:smokes cigarettes 4-5 per day since 40years 

Occasional alcoholic for 5years, stopped since 1 year

General examination: 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema of foot.






Vitals:

Bp:110/8mmhg

PR:87bpm 

Rr:20cpm 

SpO2-98 on RA

CVS- s1s2 heard; no murmurs 

RS- Bilateral air entry present 

Wheeze present in right infraclavicular ; right mammary and axillary areas 

PA- soft non tender 

CNS- higher mental functions intact

Investigations:

                    Ecg 



4/2/23

Hb: 14.0
Total count: 10,600
RBC: 5.14 
Plt: 3.49 

RBS: 93

2D echo on 6/2/23 
Mild TR+ , No MR/AR 
No RWMA. No AS/MS, sclerotic AV 
Fair LV function 
Diastolic dysfunction +, no PAH/PE 
EF: 54% 

USG ABDOMEN AND PELVIS: on 6/2/23 
Impression: 
B/L renal cortical cysts 
Significant PVR.

RFT on 6/2/23 
Urea:20 
Creatinine: 0.9 
Uric acid: 5.9 
Calcium:10.0
Phosphorus:2.7 
Sodium: 134 
Potassium: 3.5 
Chloride: 100

Treatment:


Nebulisation with budecort and duolin 6th hourly 

Tab ECOSPRIN AV 75 /10 mg po h/s 

Tab PAN 40 mg PO/ OD 

Tab DYTOR 10 mg PO / BD 

Tab MET-XL 25 mg PO/OD 

Tab TELMA 40 mg PO / OD 

Syp CREMAFFIN PLUS 15 ml PO/ H/S

Inj OPTINEURON in 100ml NS / OD 



7/2/23

HB: 14.2

TLC:13,000

RBC: 5.15

PLT:3.49


Sr. Calcium: 9.8

Phosphorus:2.6

Sodium: 129

Potassium: 4.1 

Chloride: 92 

Calcium ionized: 1.12


8/2/23

Hb: 14.0

TLC: 11,000

RBC: 5.05

PLT:3.48


CUE:

Albumin:++

Pus cells: 4-6 

Epithelial cells: 1-2 

Red blood cells: 6-8 

A










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