68 Y/M with C/O SOB, Chest pain and giddiness

 This case has been given to solve in an attempt to understand and analyse the patient's clinical data, and develop my competency in reading and comprehensive study on the clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.



MED CASE:

68 Y/M WITH COMPLAINTS OF SOB, CHEST PAIN AND GIDDINESS SINCE 2 MONTHS. 


COMPLAINTS:

C/O SOB, CHEST PAIN AND GIDDINESS SINCE 2 MONTHS.


HISTORY OF PRESENT ILLNESS:

PT WAS APPARENTLY ASYMPTOMATIC UNTILL 2 MONTHS BACK THEN HE DEVELOPED CHEST PAIN WHICH WAS NON RADIATING, LOCALIZED. HE GETS EXERTIONAL DYSPNEA WITH CHEST PAIN WHILE WALKING, WHICH RELIEVED UPON REST. HE ALSO C/O SOB AND GIDDINESS SINCE 2 MONTHS. 

NO C/O ORTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNEA AND PEDAL EDEMA. 

NO C/O FEVER, NAUSEA, VOMITING, HEADACHE, COUGH, COLD, LOOSE STOOLS, BURNING MICTURITION.



PAST HISTORY:

KNOWN CASE OF HTN SINCE 2 YEARS ( ON UNKNOWN MEDICATION)

KNOWN CASE OF DM 2 SINCE 2 YEARS ( ON TAB. GLIMI 1 MG PO/OD)

KNOWN CASE OF CVA 2 YEARS BACK AND WAS TOLD THAT HE HAS AN INFARCT IN THE BRAIN.

HE HAS A HISTORY OF PREVIOUS SURGERY FOR RENAL CALCULI 15 YEARS AGO. 

NOT A KNOWN CASE OF TB, EPILEPSY, ASTHMA, THYROID DISORDERS, CAD.  



PERSONAL HISTORY:

DIET - MIXED

APPETITE IS ADEQUATE

BOWEL AND MICTURITION ACTIVITY IS NORMAL.

ALCOHOL AND TOBACCO CONSUMPTION WAS STOPPED 15 YEARS AGO. 



ALLERGY HISTORY: 

NOT ALLERGIC TO ANY DRUGS OR FOOD



GENERAL EXAMINATION:

PT IS CONSCIOUS, COHERENT AND COOPERATIVE

No PALLOR 


No ICTERUS 


No CLUBBING


No CYANOSIS


No LYMPHADENOPATHY


No EDEMA 


TEMP- AFEBRILE


BP- 150/80 MM HG 


PR- 76 BPM


RR- 18CPM


GRBS - 163 MG/DL



SYSTEMIC EXAMINATION:


CVS - S1 S2 HEARD. NO MURMURS


RS- BLAE +, NORMAL VESICULAR BREATH SOUNDS. NO ADDED SOUNDS HEARD. 


ABDOMEN EXAMINATION:

Inspection: 

Abdomen is soft and distended. 

No sinuses,scars, pulsations, peristalsis.

Umbilicus is central and inverted. 

All quadrants of Abdomen move equally with respiration.


Palpation: 

Abdomen is soft on palpation and no tenderness noted in any quadrants. 


Percussion:

Resonant note is heard on percussion

shifting dullness negative


Auscultation:

Bowel sounds are heard.



CNS- NO FOCAL NEUROLOGICAL DEFICITS. 







INVESTIGATIONS:


RBS - 121 MG/DL


CUE:

ALB - NIL

SUGAR- NIL

PUS CELLS - 2-3


HEMOGRAM: 

HB- 12.7

TLC - 7400

PCV- 39.5

MCV- 80.5

MCH- 25.9

PLT- 1.81 lakhs 


RFT: 

B. UREA- 28

S. CREAT- 2.0

Na- 134

K - 3.8

CL- 102


LFT:

TB - 0.64

DB- 0.20

AST- 14

ALT- 10

ALP -145

TP- 6.3

ALB - 3.8


2D ECHO:

- TRIVIAL TR+. NO MR/AR

- NO RWMA. NO AS/MS. SCLEROTIC AV.

- GOOD LV SYSTOLIC FUNCTION

-DIASTOLIC DYSFUNCTION+

NO PAH/PE 


USG ABDOMEN: 

IMPRESSION:

-GRADE 1 FATTY LIVER NOTED. 

- FEW RIGHT RENAL CALCULI PRESENT (LARGEST 4-5 MM) 

- B/L SIMPLE RENAL CORTICAL CYSTS PRESENT. 



PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH PARTIAL EJECTION FRACTION 

WITH H/O CVA 2 YEARS AGO. 

K/C/O HTN AND DM SINCE 2 YEARS. 



COURSE IN THE HOSPITAL: 


PATIENT GOT ADMITTED TO GENERAL MEDICINE WARD , WITH THE COMPLAINTS OF SOB CHEST PAIN AND GIDDINESS. HE HAS A HISTORY OF CVA 2 YEARS BACK AND WAS TOLD THAT HE HAS AN INFARCT IN THE BRAIN. UPON ADMISSION, HIS BLOOD PRESSURE WAS 150/80 MMHG AND GRBS WAS 163 MG/DL. BLOOD SAMPLES WERE TAKEN FOR THE NECESSARY INVESTIGATIONS. SINCE HIS BLOOD PRESSURE IS HIGH, NECESSARY INTERVENTION/TREATMENT WAS INITIATED IMMEDIATELY.  


HIS BOWEL AND BLADDER ACTIVITY IS NORMAL. HIS APPETITE IS ADEQUATE AND NO DISTURBANCE IN SLEEP DURING HIS STAY IN THE HOSPITAL. 



TREATMENT: 

1. TAB ECOSPIRIN -AV(75/10) PO/HS AT 9PM 

2. TAB GLIMI 1 MG PO/OD AT 7 AM 

3. TAB VERTIN 8 MG PO/SOS 

4. GRBS 7 PROFILE MONITORING 

5. TAB AMLODIPINE 5MG PO/OD 

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