LONG CASE - FINAL PRACTICALS GENERAL MEDICINE

LONG CASE - FINAL PRACTICALS GENERAL MEDICINE

NAME : M. NAGA VARSHA

BATCH : 2017

HALL TICKET NO. : 1701006102

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 comments on comment box is welcome.

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

A 35 year old male, bartender by occupation, resident of Sathupalli, Khammam district, came to the hospital with the following chief complaints --

shortness of breath - from 10 days
cough- from 2 days
palpitations - from 7 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 months back then

1. he developed shortness of breath on exertion - insidious onset, gradually progressive

1 month ago, he developed shortness of breath while lying down, then he visited local RMP, where he was given an injection? and symptoms subside for a while. He experienced symptoms after consumption of alcohol.
later he visited another doctor, few investigations were done and was told to have a heart problem?

2. he gave a history of cough - from 2 days

insidious onset
mucopurulent

3. palpitations

sudden in onset
no associated with chest pain

PAST HISTORY:

NO history of similar complaints in the past.
Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, hypothyroidism/hyperthyroidism, COPD, and blood transfusions.
no history of previous surgeries'

FAMILY HISTORY:

Not significance

PERSONAL HISTORY :

Diet: mixed
Appetite: reduced from past 10 days
Bowel habits: normal
Bladder habits: normal
Sleep: disturbed from past 10 day
Addictions:

(i) alcohol consumption - since 10 years

daily 250 ml of whiskey

(ii) passive smoker at workplace - since 10 years

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

Built and nourishment: moderately built and moderately nourished
Pallor: No pallor
Icterus: No icterus
Cyanosis: No cyanosis
Clubbing: No clubbing
Generalized lymphadenopathy: No generalized lymphadenopathy
Pedal edema: No pedal edema

VITALS :

Temperature afebrile
Pulse 140-160 bpm (irregularly irregular)
Respiratory rate : 30 per minute
Bp 130/90
Spo2 98%
GRBS 132 mg%

SYS TEMIC EXAMINATION :

1. CARDIO VASCULAR SYSTEM

(i) INSPECTION

The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated

(II) PALPATION

Apex beat is shifted to 6th inter coastal space , 2-3cm deviated from mid clavicular line
No parasternal heave felt
No thrill felt

(iii) PERCUSSION

Right and left borders of the heart are percussed

(iv) AUSCULTATION

S1 and S2 heard

2. RESPIRATORY SYSTEM EXAMINATION :

Inspection:

Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .

Palpation:

Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal

Percussion:

resonant bilaterally

Auscultation:

bilateral air entry present.
wheeze is present in all areas

3. ABDOMINAL EXAMINATION:

Inspection:

Shape – elliptical
Flanks – full
Umbilicus –everted
All quadrants of abdomen are moving with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.

Palpation :

No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity

Percussion:

There is no fluid thrill , shifting dullness.
Percussion of liver for liver span
Percussion of spleen- dull note

Auscultation:

Bowel sounds are feeble.

4.CENTRAL NERVOUS SYSTEM EXAMINATION:

HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

Right. Left

BULK

Upper limbs. N N

Lower limbs N N

TONE

Upper limbs. N. N

Lower limbs. N N

POWER

Upper limbs. 5/5. 5/5

Lower limbs 5/5. 5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated .

INVESTIGATIONS :

1. 8\6\22 :

serum creatinine : 1.0 mg\dl
blood urea : 22mg\dl
serum electrolytes : Na+ - 138 mEq\L
K+ - 3.9
Cl- - 100

Ph : 7.43
PCo2 : 26.8 mmHg
PO2 : 76.3 mmHg
HCo3: 17.6 mmol\L
St. HCo3 : 20.4 mmol\L
TCo2 : 35
O2 stat : 94.0

HEMOGRAM :

hemoglobin : 12.0 gm\dl
TLC : 14,000
PCV : 37.6
MCV : 70.9
MCH : 22.4
RDW-CV : 16.9

LIVER FUNTION TESTS :

total bilirubin : 2.32
direct bilirubin : 0.64
SGPT : 58
SGOT : 34

2. 9\6\22 :

Ph : 7.43
PCo2 : 26.8 mmHg
PO2 : 76.3 mmHg
HCo3: 17.6 mmol\L
St. HCo3 : 20.4 mmol\L
TCo2 : 35
O2 stat : 94.0

3. 10\6\22:

HEMOGRAM :

Hb : 11.3
TLC : 17,100
platelets : 3.43

SERUM creatinine : 1.1mg\dl

4. 11\6\22:

HEMOGRAM :

hb : 12.8
total count : 14,100
platelets : 3.93
RBC : 6.04 millions\cumm

X RAY :

PROVISIONAL DIAGNOSIS:

This is a case of atrial fibrillation and dilated cardiomyopathy.

TREATMENT :

inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min
inj AUGMENTIN 1.2gm\IV\BD
tab AZITHROMYCIN 500mg PO\BD
inj HYDRODRT 100mg IV\BD
neb with DUOLIN @ 8th hourly

BUDSCORT @ 8th hourly

inj LASIX 40mg\IV\BD
inj THIAMINE 200mg in 50ml normal saline IV\TID
tab CARDARONE 150mg
tab clopitab 75mg RO OD
tab ATROVAS 80MG

Fluid restriction <1.5L per day
Salt restriction <4gm per day
Strict temperature chart 4th hourly

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