45 year old female with shortness of breath, cough and peripheral edema
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Vitals on day 2
X ray on day of admission:
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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
THIS IS A CASE OF 45 YEAR OLD FEMALE WITH COMPLAINTS OF SHORTNESS OF BREATH , PERIPHERAL EDEMA, COUGH ( Type 2 DM since 4 years )
45 yr old female patient , labourer by occupation ( stopped working and is staying at home, since 4-5 years)
Patient was apparently asymptomatic 1 1/2 year back when she developed bilateral lower limb edema which was relieved on treatment.
Since 1 month she developed edema B/L upper and lower limbs and face along with abdominal distention.
She started to experience shortness of breath on exertion since 25 days , which is gradual in onset, progressive, aggrevated on exertion and relieved by taking rest.
It aggravated to dyspnea at rest since 5 days which is increased on lying down in supine position( ORTHOPNEA )
She has attacks of shortness of breath at night which wake her up.
She has associated symptom of non productive cough since 20 days which is aggrevated at night and in supine position. It is increased since 5 days.
No associated symptoms like chest pain , palpitations.
She also has complaints of decreased urine output since 10 days.
Past history
She was diagnosed with Diabetes mellitus
type 2 , 4 years back
and is on Tab GLIMI M2 BD
No history of hypertension, asthma, tuberculosis, epilepsy.
Personal history
DIET - mixed
APPETITE -decreased
SLEEP -disturbed
BOWEL AND BLADDER MOVEMENTS -
decreased urine output since 10days
ADDICTIONS - drinks alcohol occasionally about 90 ml, last intake was around 4-5 months back
Treatment history
Patient was on the following drugs
1. T. DYTOR 10 MG BD
2. T. MET XL 12.5 MG OD
3. T ATORVAS 40 MG OD
4. SYP ARISTOZYME 10 ML TID
5. T FRUSELAC 50 MG OD DAILY WITH
T. METXL 3D 50 MG OD
GENERAL EXAMINATION
Patient is conscious coherent and cooperative and well oriented to time, place and person.
Patient is well built and nourished.
Pallor present
Bilateral pedal edema upto knees
Pitting type
No icterus, clubbing, cyanosis, koilonychia, lymphadenopathy.
VITALS at admission :
BP 100/60 mm Hg
RR 22 cpm
PR 80bpm
TEMPERATURE
SpO2 98%
PR : 82bpm
BP : 180/90mmHg
Temp: Afebrile
RR : 21cpm
SpO2 97 %on oxygen
Systemic examination:
CVS:
S1 S2 +,no murmurs heard, no added sounds
Respiratory System:
On palpation:
Decreased bilateral chest movements
Decreased tactile vocal fremitus
On auscultation :
BAE+
Decreased breath sounds
B/L inspiratory crepitations in all lung fields
P/A: abdomen is distended .
CNS : No focal neurological defecit.
Other images
Investigations:
Hemogram
RADIOLOGICAL FINDINGS
X ray on day 3 :
PROVISIONAL DIAGNOSIS
Acute on chronic heart failure ( heart failure with preserved ejection fraction EF :56%)
Anemia under evaluation
Treatment
1. Head end elevation
2. Inj. LASIX40 mg IV TID
3. Tab. METXL 12.5 mg PO OD
4. TAB. ATORVAS 40 mg PO OD
5. FLUID RESTRICTION <1L/ DAY
6. SALT RESTRICTION. < 2 gm/ day
7. Daily weight monitoring
8. STRICT I/O CHARTING
9. INJ. H.ACTRAPID INSULIN SC ACC. TO SLIDING SCALE 8 AM - 2PM- 8 PM
10.O 2 SUPPLEMENTATION TO MAINTAIN SPO2
11.Tab Amlong 10mg po/OD
12. MONITOR VITALS
Bp monitoring 4th hrly
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