Atrial fibrillation
A 70 year old female with Abdominal distension and Shortness of breath ;
This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
K.shirisha
Rollno;60, 8th semester
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 diagnosis and treatment plan.
Contains information collabated from Dr.sai Charan sir (pgy-1),Dr.kusuma mam ( intern) and from the patient.
Case Discussion;
A 70 year old female presented to casuality with complaints of Distension of abdomen and shortness of breath Grade-3 since 5days
History of present illness
The patient was apparently asymptomatic 5 days ago then presented with
Abdominal distension since 5 days
Onset - gradual and progressive
Distension is generalized
SOB - Grade 3 ; since 5days incidious in onset gradual in progeression
K/C/O; Hypothyroidism since 5 years
No History of palpitations ,pedal edema,oliguria,fever,cough,fatigue,
History of past illness ;
Hypothyroidism since 5 years
No history of hypertension,diabetes asthma tuberculosis.
Treatment history ;
she was on Thyronorm100mg OD for hypothyroidism .
Family history ; insignificant
Personal history ;
Appetite ; normal
Diet ; mixed
Bowel and bladder ; regular
Sleep; adequate
Addictions ; no
General examination ;
Patient is conscious coherent cooperative well oriented to time place person.she is well built,moderately nourished,and examined under informed consent.
Pallor ; absent
Icterus : absent
Cyanosis ; absent
Clubbing; absent
Edema: absent
Lymphadenopathy ; no generalized lymphadenopathy
Vitals
Temperature ; Afebrile
Puse rate ; feable
Blood pressure ; 110/60 mmHg
Respiratory rate ; 16 cpm
Systemic examination ;
CVS ; S1,S2 heart sounds are heared,no murmurs
Respiratory system; Elliptical, and bilaterally symmetrical chest
Both sides moving equal on respiration
Bilateral air entry present
Vesicular breath sounds- normal
Abdominal examination ; flat,distended,soft,non tender.
No visible pulsations ,bowel sounds are heared
CNS ; Intact,reflexes are elicited
Investigations ;
ECG ;
Showing Atrial fibrillation
2D Echo ;
Akinetic segment in LAD territory with EF 35% and RVSP 100mmhg
B/L pleural effusion,mild pericardial effusion.
Troponin-l;
Comments
Post a Comment