A 42 year old with HEART FAILURE WITH REDUCED EJECTION FRACTION

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


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

CHIEF COMPLAINTS:

C/O left shoulder pain since morning 11am radicating to chest 

C/O Shortness of breath from morning 11AM

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 11 days back he suddenly developed 

-chest pain radiating to left shoulder and was associated with sweating and palpitations.

-  He went to KIMS, NKP and was diagnosed with inferior wall MI + posterior wall MI. He was referred to KHL and was managed conservatively. 

-Later he was asymptomatic till today morning 11AM, where he suddenly developed left shoulder pain radiating to chest(dragging  type) and not associated with sweating, palpitations, nausea, vomiting, giddiness, 

(ii)shortness of breath 

-GRADE III - GRADE IV, 

-orthopnea +

-no PND 

- K/C/O CAD since 12days 


PAST HISTORY 


not a known case of HTN, DM, TB,CVD, thyroid disorders epilepsy

No history of surgeries

PERSONAL HISTORY :

  1. Diet: mixed
  2. Appetite: increased
  3. Bowel habits: normal
  4. Bladder habits: normal
  5. Sleep: normal
  6. Addictions:        
                            (I) alcohol - 90ml per day since        20 years 
                            (ii) smoking - 10-20 per day since 20 years
                             
FAMILY HISTORY :

Not significant 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.
Examined after taking valid informed consent in a well enlightened room.
  • Pallor          - absent
  • Icterus        - absent
  • Clubbing    -absent
  • Lymphadenopathy    - absent
  • Cyanosis     - absent
  • Pedal edema  -absent



VITALS :
  • Temperature - 98.6 F
  • Pulse : 96 bpm 
  • Respiratory rate : 28 per minute 
  • Bp 100/80 mmHg
  • Spo2 98%
  • GRBS 122 mg%

CVS EXAMINATION 

 S1 S2 heard
no murmurs

RESPIRATORY SYSTEM
Bilateral air entrty present
NVBS

PER ABDOMEN 

soft, non tender

CNS EXAMINATION : 

No focal neurological deficits

INVESTIGATIONS























PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH REDUCED EJECTION FRACTION





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