general medicine case-6

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.

A 70-year-old female Patient came to the OPD with the complains of shortness of breath since 15 days aggravated since yesterday 

Complains of tingling sensation all over the body since 15 days

History of present illness:

Patient was apparently a symptomatic four years back then in January 2018 she developed vomitings shortness of breath chest discomfort went to hospital and diagnosed with coronary artery disease(left anterior descending artery) and was referred to higher Centre -Angiogram was done and stent was placed 

She is on regular medication till two years 

After follow-up, she stopped taking medication and was only taking herbal medication for joint pains 

Two months back she had a similar episode and diagnosed with coronary artery disease(right coronary artery) -Angiogram was done, revealed triple vessel disease 

Since 15 days patient had SOB associated with tingling sensation all over the body

 no chest pain 

 no palpitations

 no Pedal Oedema 

History of past illness:

known case of coronary artery disease with surgical procedure percutaneous transluminal coronary angioplasty

No diabetes and hypertension

Personal history:

Patient is married home maker by occupation 

appetite normal 

regular bowel and bladder moment 

no allergies 

no addictions

Family history:

No significant family history

Examination

General examination:

patient is concious cooperative and coherent

vitals: 

temperature 97.5°F

Pulse rate 60 BPM 

Respiratory rate 18 CPM

BP 100/70 MMHG 

SPO2 98 @ RA

CVS:

 S1 S2 +

Respiratory system:

 NVBS+

P/A- soft non-tender

CNS 

- NO FND

Provisional diagnosis :

known case of coronary artery disease tricuspid valve disease (post percutaneous transluminal coronary angioplasty) 

severe left ventricular dysfunction with ?Cardio-renal syndrome type II

Investigations:

Hemogram:

Complete urine examination:

Treatment :

Fluid Restriction 1 L per day

Salt restriction less than 2.4 g per day 

Injection Lasix 40 mg/IV/BD

T. ECOSPORIN-Gold 75/40 MG/PO/HS

T.CARDIVAS 3.125 mg/PO/OD

T.PAN 40 MG/PO/OD (BBF)

T. B-COMPLEX PO/OD 

Strict I/O charting

Monitor vitals hourly