A 55 y/o woman with SOB and sweating

A 55 y/o female with SOB and sweating 

1 September 2022 

Manvi Sharma 

2018 batch (roll no 88) 

Note - This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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.

Case - 

A 55 y/o female , resident of Ramanapet presented to the casualty with the chief complaints of SOB and night sweats since 2 hrs

 

History of presenting illness-

6/7/21

The patient was apparently alright 1 year ago, then she experienced chest pain and increased sweating. She was referred to a Cardiac specialist in Nalgonda where some tests were run.

She went to Apollo hospital DRDO wherein stenting operation was performed, 2 stents were placed.  She stayed in the hospital for a week and got discharged. 

26/12/21

About 8 months back she complained of SOB, fever and cold. She came to KIMS NKP where she was diagnosed to have bronchopneumonia and treated appropriately. 

28/1/22 

She went to Apollo hospital wherein troponin-i test was performed and found to be positive. Medication was given. 

As of 1/9/22

She came to our casualty at around 3 in the night with complaint of SOB(grade 4) and increased sweating since 1am and 2 episodes of vomiting which is consisting of food particles and is non-bilious & non-projectile.

Past history -

She is a k/c/o HTN since 6 yrs 

K/c/o ACS CAD stent placement (2021)

Not a k/c/o DM, TB, asthma, epilepsy, CVA 

 

Personal history- 

She is a mother of three. Before her operation was performed she used to do cooking business from home selling idlis and bondas. Since 1 year she is just doing daily household chores. 

Appetite - normal 

Diet - mixed 

Bowel & bladder movements - regular 

Sleep - adequate 

Addictions - none 

Family history -

No significant family history 

Drug history -

General physical examination - 

The patient is conscious, coherent, cooperative and well oriented to time, place and person. 

She is having abdominal obesity. 

No pallor 

No icterus 

No cyanosis

No clubbing 

No lymphadenopathy

No pedal edema 

 Vitals-

Temp- Afebrile 

PR - 92 bpm

RR- 21 cpm

BP - 120/80 mm Hg 

SpO2- 98%

GRBS - 180mg/dl 

Systemic examination - 

CVS - S1, S2 heard, no murmurs 

RESPIRATORY SYS- trachea central, BAE+, normal vesicular breath sounds heard, b/l diffuse crepts heard 

CNS - no abnormality detected 

ABDOMEN - obese, soft, non tender, no organomegaly 

Investigations - 

6/7/21

 

27/1/21

1/9/22 & 2/9/22

Provisional diagnosis-

Acute on chronic LVF with flash pulmonary edema with old CAD 

(PTCA 2021) 

Treatment given-

INJ LASIX 40 mg /IV / BD 

TAB ECOSPRIN GOLD 20/ PO

TAB MET- XL  25mg /PO/OD

TAB CARDACE  2.5 mg/PO/ OD

INJ RANTAC 50mg/IV/OD

INJ ZOFER 4mg IV SOS

INJ MONOCEF 1gm/IV/BD

STRICT I/O CHARTING 

VITALS MONITORING 

She was referred to higher cardiac centre for consultation.