65 F, SOB at rest

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I have 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

A 65 year old female patient came to opd with chief complaints of shortness of breath at rest since 3  days

History of present illness:

Patient was apparently asymptomatic 3  days back then she developed shortness of breath,she got sob  insidious in onset,gradually progressive to current state that is grade 4.

3 days back at night she had sob insidiously ,(SBP-180)for that her grandson who works in pharmacy gave her a deriphylin ampule ,for which she got relieved and again her symptoms are exacerbated at morning,which made her to bring to the hospital. 

H/o orthopnea since 3 days

H/o palpitations since 2 months

H/o weight loss from 1week

No h/o cold,cough ,fever,pnh

1 week back her second son got into RTA  for which she got tensed and doesnt eat well.

H/o excessive sleep.(OSA?)

6months back she has localized unilateral swelling on left dostum of foot associated with pain relieved by Nsaid  and then on to right side which was healed by hyperpigmentation (PAD?)

From 2years H/o pain in legs  and sob for walking approx 1km.

Exertional sob

Yesterday, she has localized retrosternal pain at edge of the manubrium .

From 2 days she has diffuse abdominal pain .

Past HISTORY:

she has hypertension from 10 years and diabetes from 5 years for which she is using amlodipine and glimiperide.

No h/o asthma, epilepsy, tuberculosis. 

No previous hospitalizations

She has left ear discharge with left ear hearing loss 3 years ago

Personal history:

She is an elderly female with two sons and one daughter confined to home ,not doing any work from past 5 years .She terminated her work as a labourer as she ageing and leg pains. In home she gets up at 6 ,do her daily routine activities and sit watch tv .Her husband died 15 years ago.As per family members,she used to get tensed for small issues.

She has Gastric problems,she uses pantop occassionally based on bloating

Family history: No significant

Treatment history: amlodipine,glimiperide,pantop

General examination

She is thin built and moderately nourished

She has visceral fat with waist to hip ratio

Pallor present

Jcterus cyanosis, clubbing lymphadenopathy, edema absent

VITALS:

On 19 march ,

Fever-97.4

Pulse rate-108, rhythm-regularly irregular,volume,character,peripheral pulses felt 

Blood pressure in sitting position:

Respiratory rate :22 cpm,regular,

Grbs:220 mg/dl

Vitals chart:

SYSTEMIC EXAMINATION

CVS

on inspection

Apex beat: in 5th intercoastal space

Jvp

Palpation:

Apex beat at 5th intercoastal space at midclavicular line

Auscultation:In mitral ,tricuspid,aortic,pulmonary areas S1,s2 are heard

 Rhythm regularly irregular 

Lung:

Inspection: chest shape normal, 

Palpation: trachea -central,sternal tenderness is noted yesterday

Percussion: dull note in inframammary and mammary regions

Auscultation: basal crepitations are heard

Per abdomen

On palpation visceral fat is more organs cannot be palpated

hearing impaired

Tuning fork tests: 

         Right     left

256   BC>AC  BC>AC

512   AC >BC    BC>AC

Squint present

CNS: 

MANAGEMENT 

INVESTIGATIONS:

On the day of admission

CBP

Hb:10.4

TLC:14,400

Neutrophils: 83

Lymphocytes:10

Smear: normocytic normochromic Neutrophillic leukocytosis

Hba1c:7.2

RBS:332mg/dl

RFT

(17,19,20,)Urea:50,81,96

(20,22)Creatinine:2.2 ,3.2

(17) Uric acid:10.1

Calcium-10

Phosphate-4.1

Serum electrolytes 17/19/20/22

Sodium: 139, 138,137,130

Potassium:4.5,3.9,3.6,4.3

Chlorine:99,99,98,95

LFT

Totalbilirubin:1.31

DB-0.20

Ast:13

Alt :10

Alp:184

Almunin: 3

18/03 , 19/03,20/03,

Ph : 7.46 , 7.48 ,7.46 

Pco2: 15.7,13.2,20

Po2:88.3,147,135

Hco3: 11.2,9.9,14.2

StHco3: 16,15.0,18.0

Interpreation: Respiratory alkalosis,high anion gap metabolic acidosis with metabolic alkalosis.

Echo shows global hypokinesia

VIDEO:

https://youtu.be/RBzRWh9Qiro

CHEST X-RAY:

On 22 march, 

Patient is on non invasive ventilation  due to increased SOB.

Patient is wanting to leave against medical advise.

Treatment:

  INJ. LASIX 20 mg IV TID

2. TAB. ECOSPIRIN -AV PO / H/S

3. TAB. AMLONG 5MG PO /OD

4. Inj. HUMAN ACTRAPID S/C ACC TO SUGAR VALUE

5. TAB. PANTOP 40 MG PO /OD

6. TAB. ISOLAZINE 20 MG PO /BD

7. MONITOR BP , GRBS, INFORM SOS

8.  Fluid RESTICTION ( < 1 LT /DAY)

9. SALT RESTRICTION (< 2GM/ DAY)