A 73 y/o female with SOB and chest pain since 2 days

 

73 year old female with SOB and CHEST PAIN since 2 days

M.sandhya 

march 3rd,2023

This is an 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 inputs on the comment box

73 year old female who is a home maker and came to opd with

CHIEF COMPLAINTS;
 shortness of breath and chest pain since 2 days

 
HISTORY OF PRESENT ILLNESS;
Patient was apparently asymptomatic 15 years back and gradually developed weakness (generalized) and went to hospital and diagnosed with type 2 DM and HTN and was prescribed medication.she was fine till 15 days back and then she developed fever with generalized weakness and went to hospital and diagnosed to have ?chronic kidney disease with base line creatinine 2.9 

PAST HISTORY 
k/c/o      HTN  since 15 years and on regular medication 
k/c/o,DM type 2 since 15 years and was on OHAS
for 7 years and then later shifted to insulin.
presently on inj.MIXTARD,25 U (M) and 20 U(night)

FAMILY HISTORY:-
insignificant 
PERSONAL HISTORY:-

DIET-mixed
APEPTITE- decreased 
BOWEL &BLADDER-Regular
SLEEP; adequate

GENERAL EXAMINATION:-
Patient is conscious , coherent,cooperative.
Well oriented to time place & person 
Moderate built and moderately nourished.
Pallor present
No cyanosis, clubbing, icterus, LN
B/L pedal edema present
Vitals : 
Bp -170/100mmhg
PR -110 bpm ;
RR : 22cpm
Spo2 : 94 on RA
GRBS:339mg/dl
CNS examination:
SYSTEMIC EXAMINATION :
CENTRAL NERVOUS SYSTEM;

CNS:                 R                L
Tone-  UL         N                N
            LL           N                N
 Power-UL        4/5            4/5
             LL        4/5            4/5
 Reflexes- Biceps- +        +
                 Triceps- +       +
                 Supinator- +    +
                 Knee-    +       +
                 Ankle-  +          +
                 Plantar- flexion   flexion
Sensory examination: Normal
Rhomberg's negative
Cerebellum:
Nystagmus-absent
Tremors- absent
Finger nose test- normal
Dysdiadokinesia -absent
CARDIOVASCULAR  SYSTEM:

S1 S2 heard 
No murmurs.
RESPIRATORY SYSTEM:-
Dyspnea- No
No wheeze
Breath sounds - vesicular
No Adventitious sounds 
ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.


INVESTIGATIONS:-














ECG;

CHEST X-RAY

2D-ECHO

USG ABDOMEN:



TREATMENT;

1. Inj.lasix 40 mg I.v/BD if SBP greater than 110 mmgh
2.T.shelcal 500 mg po/OD 
3.T.nodosis 500 mg po/OD
4.T.orofer XT PO/OD
5.T.cinod 10 mg po/OD
6.T.Met-XL 12.5 mg PO/OD
7.inj.Human actrapid insulin s/c TID acc to sliding rule
8.GRBS charting
9.T.Ecosprin Av 75/10 PO/HS
10.I/O charting




Comments

Post a Comment

Popular posts from this blog

General medicine case discussion

Online blended bimonthly assignment toward summative assessment for the month of May 2021 M.SANDHYA ROLL NO: 89 8th sem Pulmonology (10 Marks)  A) Link to patient details: https:// soumyanadella128eloggm. blogspot.com/2021/05/a-55- year-old-female-with- shortness-of.html Questions: 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? 2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient? 3) What could be the causes for her current acute exacerbation? 4. Could the ATT have affected her symptoms? If so how? 5.What could be the causes for her electrolyte imbalance? 1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is th
Read more

80 year old female with SHORTNESS OF BREATH AND COUGH

Image
80 year old female with SHORTNESS OF BREATH AND COUGH June 6, 2022 M.sandhya 1701006117 This is an 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 inputs on the comment box 80 year old female who is dailywaged labour by occupation and came to opd with CHIEF COMPLAINTS;   shortness of breath since 10 days  dry cough since 3 days HISTORY OF PRESENT ILLNESS; Patient was apparently asymptomatic 20 yrs back then  she had history of giddiness and headache  for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab
Read more

CASE OF A 40Y/M WITH PAIN ABDOMEN & VOMITINGS

Image
This 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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. CASE: A 40 year old male tractor driver by occupation came to the opd with the chief complaints of pain abdomen since 3 days and vomiting since 2 days. History of present illness : patient was apparently asymp
Read more