INTERNAL ASSESSMENT ( PRACTICAL )
This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan
SHORT CASE :
65 /F came with chief complaints of
Both lower limb swelling since 1 week
Breathlessness since 1 week
History of present illness :
Patient was apparently asymptomatic 1 week back then she developed swelling intially started at lower limbs gradually progressive to whole body associated with breathlessness insidious onset, non progressive of grade 2 according to mmrc since 1 week and associated with decreased appetite since 5 days.
No history of orthopnea , PND, chest pain, palpitations, sweating, decreased urine output, pain abdomen, Nausea , vomitings
Life events :
Born to nonconsangeinous parents, 2 nd order child ( she have 1 elder brother and 2 younger brothers ) , fine till few years , according to patient during her childhood ( didn't remember the correct age ) when she got fever she was treated with some pasaru ( extracted from plant ) into her ears to get relief from fever ,she started experiencing decreasing hearing in both ears since then according to patient , married at age of 12 years to a person( his 1st wife expired) , he married her after her demise , gave birth to one child (but expired after birth : Reason not known ), 2 nd child now currently at age 36 , married have 1 son and 2 daughter's . None of his family members, have hearing loss .
She started working from from age of 14 years , used to work in farm , wakes up at 5 am does her daily activities, and prepared food for her and her family members, eats rice and curry then go to farm and in afternoon she again takes rice and curry, after her work she returns home at 4pm , and she does the household works like sweeping floor , washing clothes and cleaning the utensils and by 9pm everyone will have dinner and goes to sleep by 10 pm . This was her routine till 40 years of age , after that his son got married and after his son had children stopped working to take care of of her grand children. After her son's marriage, she does only evening household works as both her son and daughter -in -law goes to work . Her hearing loss didnot troubled her much as everyone used to talk in high pitch for her better hearing . But this hearing intensity decreasing since 10 to 12 years though it didn't bothered her much and doesn't seek any medicial attention
Past history :
H/of trauma to spine 5 years back , consultated a doctor said to have decreased bone density ? osteoporosis
Decreased hearing since childhood
Not a k/c/of HTN , Diabetes, Asthma , CVA, CAD Epilepsy
Personal history
Appetite : Decreased since 5 days
Sleep : Regular
Bowel and bladder : Regular
Addictions : Occosional toddy drinker since 30 years ,stopped since 1 year
Past history : No significant family history
General Examination :
Head to toe examination :
PR : 115 bpm
BP: 130/90 mm of hg
RR : 26 cpm
SpO2 : 98 on RA
GRBS : 237 mg/dl
JVP : Raised
Pedal odema + bilateral pitting type
Facial puffiness +
No Pallor ,cyanosis, clubbing , lymphadenopathy
Abdominal circumference : 91 cms
Midarm circumference: 26 cms
Skin fold thickness 19mm
Midarm muscle circumference: 20.04 cms
FM ratio : 4.54
Systemic Examination :
Cardiovascular :
Inspection : Jvp : Elevated
Palpation :
Apex beat 6th Intercoastal space midclavicular line
No Parasternal haeve
Percussion : Normal
Ascultation : S1, S2 +, No murmurs
Respiratory system :
Ascultation : bilateral IAA , ISA , IMA crepts +
Per abdomen :Mildly distended , soft, Nontender
Central Nervous System : Positive findings mentioned :
8th Cranial Nerve :
Rinners : bone condition more than air conduction in both ears ( L more than right )
Webers : Able to perceive in both ears ( L> R)
Investigations :
Hb:- 9.9gm/dl
TLC:- 9900 cu mm
Neutrophils :- 73%
Lymphocytes :- 17%
Monocytes :- 6%
Eosinophils:- 4%
PCV:-31.9%
MCV:- 97.6 fl
MCH:- 30.3 pg
MCHC:- 31%
RBC:- 3.27 million/cumm
PLATELETS:- 2.23 lakhs /cu mm
Peripheral smear : Normocytic Normochromic anaemia
COMPLETE URINE EXAMINATION:-
Pus cells- 3-4
Epithelial cells :- 2-3
Albumin :- Trace
Sugars :- Nil
No RBC , No casts
RFT :-
Urea:- 64 mg/dl
Creatinine:- 3.5 mg/dl
Sodium:- 140 mEq/L
Potassium:- 4.5 mEq/L
Chloride :- 104 mEq/L
LFT:-
Total Bilirubin :- 0.49 mg/dl
Direct Bilirubin:- 0.15 mg/dl
AST:- 13 IU/L
ALT:- 13 IU/L
Alkaline phosphatase:- 504 IU/L
Total proteins :- 5.8gm/dl
Albumin :- 3.45 gm/dl
A/G ratio:- 1.47
ECG :
Chest xray
Diagnosis : Heart failure with ? Preserved Ejection fraction secondary to ? Metabolic syndrome with Acute renal failure ( ? Prerenal )Conductive hearing loss in both ears ( L>R )
Score : ( H2FPEF)
BMI: <32( 2 points)
Not on only 1 anti hypertensive (0 points)
No atrial fibrillation (0 points)
RVSP:35mmhg(0 points)
Age >60years(1 point)
Filling pressure E/e’ (<9 ) : (0 points )
Total score :3
https://www.jacc.org/doi/10.1016/j.jacc.2023.03.393
Treatment :
Inj frusemide 40 mg iv/BD
IV fluids urine output +30 ml/hr
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