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;

Complete blood picture ;

Serum electrolytes;

Hiv1/2rapid test;

Glycated hemoglobin;

C-reactive protein;

Blood sugar random;

Anti Hcv Antibodies -Rapid

Blood urea

HBsAg: Rapid

Serum creatinine ;

Diagnosis;

  HFrEF with Atrial fibrillation 2 to ?IHD

Treatment plan;

✓ Inj. Amiodarone 150 mgIV stat (2 doses)

✓Inj.Amiodarone infusion

 1mg/min till 6hr f/b 0.5 mg/min for next 18 hours

✓ Inj.clexane 40mg Sc OD

16/06/2021 

Her biochemical report showing severe hyperthyroidism possibly relating to her refractory Atrial fibrillation 

* And attempted for Defebrillation 

( Unfortunately she had passed away).