general medicine case-6
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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
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