Monday 6 June 2022

1701006077 - long case final mbbs practical

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 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-centred online learning portfolio and your valuable inputs on the 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


● Hallticket no.1701006077


               Timeline of  An 82 year old female resident of nalgonda









Personal  history : 
▪︎diet: mixed
▪︎Appetite-normal
▪︎bowel and bladder-regular
▪︎sleep-inadequate
▪︎addictions - alcohol occasionally 
Family history : insignificant

General Examination : at the time of admission


Patient was conscious,Oriented,Comfortable and Co-operative

Moderate Built and Nourishment


▪︎ afebrile

▪︎Palor: present

▪︎ Icterus-no

▪︎No Cyanosis-central/peripheral

▪︎ No Clubbing – bilateral/unilateral

▪︎ Pedal edema – bilateral

▪︎ No lymphadenopathy

 

▪︎ on examination


Patient is conscious,Oriented,Comfortable and Co-operative

Moderate Built and Nourishment


▪︎ afebrile

▪︎Palor: present

▪︎ Icterus-no

▪︎No Cyanosis-central/peripheral

▪︎ No Clubbing – bilateral/unilateral

▪︎ No Pedal edema – bilateral/unilateral

▪︎ No lymphadenopathy

 
















 ●Vitals : at the time of admission


Bp -140/70 mmhg
PR -48 bpm irregularly irregular
RR : 26 cpm

Spo2 : 84 on RA, 96 On 4lts O2


 ● VITAL SIGNS on examination


On day 2

 

PULSE: 55bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 22cpm

 

TEMPERATURE: afebrile

 

▪︎ Shortness of breath at rest improving


On day 3 


PULSE: 56bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 130/80 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 20cpm

 

TEMPERATURE: afebrile


▪︎Shortness of breath at rest improving


On day 4


PULSE: 60bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 20cpm

 

TEMPERATURE: afebrile 


▪︎Shortness of breath at rest improving



● SYSTEMIC EXAMINATION:



At the time of admission 
 
▪︎Cvs: jvp slightly elevated
Apex beat 2cms lateral to midclavicular line 
S1,S2 heard
No murmurs

▪︎Rs: bilateral air entry present , B/l lower zone crepts presents




CXR : cardiomegaly with the features of pulmonary edema

▪︎Per abd :-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present

▪︎CNS:-
Higher mental function- intact
Normal - cranial nerves

Normal- motor and sensory system.


On examination on day 2 of admission 

▪︎CARDIOVASCULAR SYSTEM:- 
        
On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins





▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.

▪︎RESPIRATORY SYSTEM:-
Dyspnea- present
No wheeze
Breath sounds - vesicular
No Adventitious sounds 

▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is conscious ,coherent and cooperative 

                Language and speech are normal

                Cranial nerves :- intact 

Sensory system :- 

Sensation                   right                    left

Touch                        felt                       felt

Pressure                     felt                       felt 

Pain 

-superficial                felt                        felt

-deep                         felt                       felt

Proprioception          

-joint position         ✔                     ✓

-joint movement    ✔                      ✓   

Temperature         felt                      felt

Vibration                felt                      felt

Stereognosis           ✔                       ✓

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


Gait :- Normal

Superficial and deep reflexes are elicited

No signs suggestive of cerebellar dysfunction




On day 3 : 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.

▪︎RESPIRATORY SYSTEM:-
Slight Dyspnea present
No wheeze
Breath sounds - vesicular
No Adventitious sounds 

▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is consious coherent and oriented

                      Language and speech are normal

                Cranial nerves :- intact 

Sensory system :- 

Sensation                   right                    left

 Touch                        felt                       felt

Pressure                     felt                       felt 

Pain 

-superficial                felt                        felt

-deep                         felt                       felt

Proprioception          

-joint position         ✔                     ✓

-joint movement    ✔                      ✓   

Temperature         felt                      felt

Vibration                felt                      felt

Stereognosis           ✔                       ✓


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


Gait :- Normal

Superficial and deep reflexes are elicited

No signs suggestive of cerebellar dysfunction



On day 4: 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.


▪︎RESPIRATORY SYSTEM:-
Dyspnea resolved
No wheeze
Breath sounds - vesicular
No Adventitious sounds 

▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is conscious ,coherent and cooperative 

                 Language and speech are normal

                Cranial nerves :- intact 

Sensory system :- 

Sensation                   right                    left

 Touch                        felt                       felt

Pressure                     felt                       felt 

Pain 

-superficial                felt                        felt

-deep                         felt                       felt

Proprioception          

-joint position         ✔                     ✓

-joint movement    ✔                      ✓   

Temperature         felt                      felt

Vibration                felt                      felt

Stereognosis           ✔                       ✓


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


Gait :- Normal

Superficial and deep reflexes are elicited

No signs suggestive of cerebellar dysfunction



INVESTIGATIONS:-

PREVIOUS- 18-06-2020

2d echo
 
Left atrium dilated
Left ventricular hypertrophy



● Recent reports-

Day1 at our hospital


CBP
Hb 5.5gm/dl
TLC 7400
PLT 2.28L
microcytic hypochromic cells


LFT
TB :1.05
Db :0.35
ENZYMES: normal
TP :5.6
ALBUMIN: 3.68

RFT : unremarkable
Sr.Mg-1.7

Sr. LDH:  218 low
ESR :normal
Retic count : 0.5
Sr. Iron : 49mg/dl


Usg abdomen:-








Fever chart 

Ecg :

 



● PROVISIONAL DIAGNOSIS:-

HEART FAILURE WITH PRESERVED EJECTION FRACTION
WITH  CARDIOGENIC PULMONARY EDEMA.

TREATMENT:-

1)Inj. Atropine 0.5ml/iv/sos
2)Inj.pantop.40mg/iv/OD
3)Inj.lasix 40mg /iv/bd( 8:00am & 4:00pm)
4)Inj. Zofer 4mg /iv/sos
5)Tab .Ecosporin -Av 75/10mg/OD
6)Inj.CLEXANE 60mg/sc
7)Tab.OROFER-XT po/OD
8)vitals monitoring




 
























General examination: 

Moderate built and moderately nosis, clubbing, icterus, LN




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