Gm Case 2
GM case 2
vitals
73 year person came with complaints of shortness of breath swelling on his leg and pain in chest and also abdomen since 9 days.
Case Scenario:
My self Kaleru .Pranay Kumar of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.
Chief complaint:
Shortness of breath since 9 days
Abdominal and chest pain since 9 days
Pedel edema since 9 days
History of present illness:
Patient was asymptomatic 9 days back then he developed shortness of breath which is sudden and exertion i e grade 2 . Shortness of breath relived by taking rest .Pedel edema present which is pitting type
History of past illness:
4 yrs back..he went to hospital with edema in limbs and used medication. They are:
Dytor plus
Predmet 16 mg
Repan - DSR
CO 2 tab
Mucaine gel
No Hypertension
No Diabetes
Family history:
No person in his family has hypertension Diabetes asthama TB heart diseases cancer
Personal history:
He is a farmer and married.He goes to field work in the morning return late in evening.But since 10 days..he is unable to walk..as he is experiencing breathless while walking..So he visited hospital.
Appatite - Normal
Diet - Veg
Sleep - insomnia
Bowels- Regular
Micturation - regular
Addictions - Tobacco sniffing
General examination:
Thin built/ thin nourished
Consicuous
Pallor - no
Icterus - no
Cyanosis - no
Jaundice - no
Edema - yes
Temperature - afebrile
Temperature - afebrile
Bp - 120 /70 mm hg
Pulse rate- 79/ min
Respiratory cycles - 22 cycles/ min
Systemic examination:
Cardiac sounds- heard like
Bowel sound - yes
Gait - normal
Provisional diagnosis:
Heart failure
Kidney failure
Investigations:
Definitive diagnosis:
Heart failure with decreased EF
Chronic kidney failure
Dilutional hyponatremia
Treatment:
T.Hyralazine 12.5 mg
ING thiamine 200mg in 100ml
T.Ecospirin 75mg
Injection epo 4000/ iv,/ sc
Injection lasix 60 mg / BD
T.met- xl 25 mg
Questions:
How we differentiate shortness of breath related to respiratory system or other systems??
Pedel edema seen only under kidney failure or any other problems??
