Name: K.Sannith Reddy
Roll no. 65
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 :
CHEIF COMPLAINTS :
85 year old female came to the causalty with c/o shortness of breath and chest discormfort since 1 week
HOPI:
pt was apparently asymptomatic 27 years ago, had expiry of his husband (reason: attenders are saying because of old age, huaband was died).
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.
She is a vegetarian and has no addictions. She stays along with her son, who has kirana shop, and her daily routine was she used to stay at home, not used to go outside and do Pooja, have food and watches television.
15 days back, patient developed sudden onset shortness of breath, 3 hours after having dinner, along with chest discomfort and sob aggravated on lying down position,along with cough.The attenders called RMP, but due to unavailability of vehicles, the patient was at home till 5am.At around 5 am in the morning, patient was taken to the area hospital, ECG was taken, told that it was heart stroke,where where she was given a injection (taking all the consents ??Thrombolysis) and she was taken
to the private hospital in warangal.
The treating doctor performed coronary angiography and advised for conservative management.
But upon request / force by attenders, PTCA was done to LAD and 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.
PAST HISTORY :
K/C/O HTN SINCE 20 YEARS ON regular medication on metoprolol 25 mg
K/C/O DM SINCE 20 YEARS on regular medication metformin 500 mg
HISTORY OF CAD on medication ecosprin 150mg ,atorvas 40 ,clopidogrel 75
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
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
Pt is c/c/c
NO icterus,cyanosis,clubbing,lymphadenopathy,edema
Pallor present
vitals:
BP-90/50mm hg
pr- 108bpm
RR 20cpm
Spo2 -100 on6lit o2
grbs 216mg/dl
SYSTEMIC EXAMINATION:
CVS S1,S2 heard ,no murmurs
RS- BAE + ,Crepts present in B/L infrascapular region
P/A soft,nontender
CNS: NFND
INVESTIGATIONS:
2d echo:
ECG: on 5/2/23
On4/2/23
On 3/1/23
Cxray:
DIAGNOSIS:
HEART FAILURE WITH REDUCED EJECTION FRACTION WITH S/P PTCA TO LAD 15 DAYS BACK
CAG: TRIPLE VESSEL DISEASE WITH ANEMIA OF CHRONIC DISEASE WITH AKI ON CKD?
K/C/O HTN,DM SINCE 15 YEARS
TREATMENT :
INJ MONOCEF 1G IV BD
INJ LASIX 40MG IV BD
INJ HUMAN ACTRAPID INJECTION S/C ACC TO GRBS AFTER INFORMING
T CLOPIDOGREL 75MG PO BD
T ECOSPRIN 150 MG PO HS
T ATOCOR 20 PO HS
INTERMITTENT CPAP
INJ NORAD 1 MCG /KG/MIN (4ML+46ML NS)@ 2ML/HR INCREASE /DECREASE TO MAINTAIN MAP>/= 65MMHG
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