1601006096 SHORT CASE

 

SHORT CASE

1601006096 

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 IS THE CASE I HAVE BEEN GIVEN :

A 40 year old female patient, works at a construction site came to the opd with

CHIEF COMPLAINTS OF :

1. Chest pain since 5 days
2. Shortness of breath since 5 days

HISTORY OF PRESENT ILLNESS :
The patient was apparently asymptomatic 5 days ago, the she developed chest pain, non radiating &  increased on taking deep inspiration.
Shortness of breath on & off

No h/o orthopnea, PND, fever, Cough

PAST HISTORY :  Not a k/c/o DM, HTN, CAD, Asthama, epilepsy and Tb

PERSONAL HISTORY :

Mixed diet
Appetite normal
Sleep is adequate
Bowel and bladder movements regular
No addictions

FAMILY HISTORY : Not significant

GENERAL EXAMINATION :

• She is conscious,coherent and cooperative
• Moderately built & moderately nourished
• No Pallor, icterus,clubbing,cyanosis,koilonychia and lymphedeopathy

BILATERAL PEDAL EDEMA present, pitting type ,grade 2

• JVP is raised - 7cm


VITALS :

 •Afebrile
• PR : 102 bpm, regular rythm, normal volume, no radio radial & radio femoral delay, condition of the arterial wall is normal.
• RR : 18 cpm
• B.P : 110/80 mm hg, measured in right hand supine position


SYSTEMIC EXAMINATION :

• CVS : S1, S2 + , No added murmurs

• RS : NVBS, bilateral air entry present, no added sounds

• CNS : 

All higher motor functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

• P/A : Soft, non tender, no organomegaly, bowel sounds heard

INVESTIGATIONS :

Complete blood picture : 



ECG :


COLOUR DOPPLER 2D ECHO



PROVISIONAL DIAGNOSIS : 
 HEART FAILURE  (EARLY STAGE)


TREATMENT GIVEN :

Tab. Nexpro 40 mg OD
Syrup sucralfate 10 mg TID



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