Medicine case discussion

 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

K.shirisha

Rollno;68

70yr old female 

Came to casualty with chief complaints of cough since 1 week 

Fever since 1 week, sob since 6days 

And loose stools since 4days

History of present illness:

Patient was apparently asymptotic 1 week ago, then she developed cough, sudden in onset, associated with sputum which was white in colour, scanty,non blood stained and non foul smelling 

Cough associated with abdominal discomfort and chest tightness

Fever since 1 week high grade associated with chills and rigours and no diurnal variation, relieved with medication

Shortness of breath progressed from grade 1 to 2, increases on exertion , no Orthopnea , no pnd 

No chest pain , palpitations

No c/o tingling and numbness

Patient went to local doctor and was transfused 1 point RBC I/v/o severe anemia 

Past history - history of similar complaints 3 years ago transfused 2 point rbc at that time 

Personal history:

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Addictions: occasional toddy drinker

Menstrual history:

Age of menarche: 13 years

Attained menopause 25 years ago

Family history: insignificant

On general examination -

Patient was conscious, coherent, cooperative

 pallor : present

Hyperpigmented knuckles

Icterus: absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

left pedal oedema present since 12yrs , pitting type - present now also

Systemic examination:

CVS- 

Inspection;

Position of trachea ;midline

No visible pulsations,

Jvp raised:

https://youtube.com/shorts/bhKhS14tgcY?feature=share

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , 

Ejection systolic murmur heared on mitral area

Respiratoy- bilateral air entry present ; no abnormal air sounds heard 

Per abdomen- soft and non tender 

Bowel sounds heard 

Cns - conscious and oriented 

Higher mental functions - intact

Diagnosis - 

1. heart failure 0(high output)

2.  iron deficiency Anemia secondary to   ?blood loss ?nutritional

Investigations:

Hemogram

HB:6.5g/dl - 6.4g/dl -7.1g/dl -8.3g/dl

TLC:6,900- 6.100 - 5,400 -6,300

Pc: 1.5 lakhs - 1.65 lakh-2.18 lakh -2.04

MCV: 24.7 - 67.9 -66.8 -67.3

Mch: 67.5 - 17.5- 18.2-18.5

Mchc: 26.3-25.8-27.2 -27.5

Rdw-cv:32.1-33-34.8 -35.4

RBC: 3.66-3.65 -3.91 -4.49

Impression: microcytic hypochromic anemia with microcytosis

d2  impression: microcytic hypochromic anemia with microcytosis and anisocytosis

Blood grouping and typing: AB positive

Esr: 45 raised

Reticulocyte count:0.7. - 0.5

Rft

Blood urea: 53 -43

Serum creatinine: 0.9 -0.9

Serum electrolytes:

Na: 131-135

K: 3.5 -4.8

Cl:106 -101

ICA: 1.00 -0.91

Lft: '

TB: 0.73

DB: 0.16

AST:14

Alt: 10

Alp: 110

TP: 5.5

Alb: 2.0

A/G : 0.58

Serum iron: 49

Serum calcium: 9.7

FBS: 73 mg/dl

Plbs: 95 mg,/dl

Ldh: 106 decreased

Serology: negative

Stool for occult blood: negative

Blood and urine culture: no growth detected

Serum ferritin: 161.3 ng/ml

Thyroid profile:

T3:0.90

T4:10.26

Tsh:7.33

USG abdomen: 

No sonological abnormality detected

Chest x ray:

2d echo:

https://youtu.be/qTS8a4lPBc8

EF:64%

Moderate mr/Tr with PAH : mild AR

No RWMA,noAS/MS,sclerotic Av

Good LV systolic function

Diastolic dysfunction,no pe

Treatment:

1) inj iron sucrose 100ml/iv/od 

2)inj ciplox 100ml/iv/bd for 3 days

3)inj zofer4mg/iv sos

4)syp grillinctus 15ml/po/Tid

5) Tab pantop 40 mg/po/od

5)Tab sporlac ds/po/Tid

6)Tab lasix 20 mg/po/bd

7) NEB with BUDECORT 12th hourly

MUCOMIST 6 th hourly