medicine case presentation

Hello everyone... I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties. 

CASE-

A 55 year old female came to the opd with the chief complaints of

                                                                    1.palpitations (since 2months)

                                                                    2.chest pain (since 2 months)

                                                                    3.associated with shortness of breath

HOPI-

patient was apparently asympotamatic 2months back then she started having chest pain on left side more on epigastrium, non-radiating

-associated with palpitations

-and started developing shortness of breath, around the same time, progressive in nature leading to present status of grade III-IV of dyspnoea.

-associated with PND (patient wakes up for air hunger) since 2 months increased in past 10days

-associated with bilateral pedal edema upto ankle since 1 week

-associated with decreased urine output since one week. (for which she took medications outside)

-no history of fluid loss

-no history of fever, cough.

HISTORY OF PAST ILLNESS-

-no similar complaints in the past

-no history of hypertension, diabetes mellitus, CKD, CAD, Tuberculosis, asthama.

-no history of rheumatic fever 

FAMILY HISTORY-

no similar complaints in the family.

no history of HTN, CAD, rheumatic heart disease, obesity, diabetes, sudden cardiac death.

PERSONAL HISTORY-

diet-mixed

appetite-decreased

sleep-decreased

bowel&bladder-decreased urine

addictions-none

GENERAL EXAMINATION-

patient was conscious, coherent and cooperative

moderately built and nourished

no pallor,icterus,clubbing,cyanosis,lymphadenopathy.

edema- bilateral (upto ankle)

dehydration-mild

vitals-

temparature-afebrile

pulse rate-feeble

BP-110/70mmHg

spO2=98%

SYSTEMIC EXAMINATION:

I.RESPIRATORY EXAM=

-dyspnoea-present (grade III-IV)

-wheeze-heard on right side

-trachea-central in position

-breath sounds- vesicular in nature, with coarse crepitations heard (right>left)

II.ABDOMEN-

shape=scaphoid

no tenderness

all quadrants moving equally with respiration

hernial orifices are full

no organomegaly detected

bowel sounds heard

III.CNS EXAM:

higher mental functions normal

cranial nerves intact

motor system- normal

sensory system-normal

IV.CVS EXAMINATION:

1.pulse- 72bpm, feeble, irregularly irregular, condition of vessel normal, pulse defecit could not be elicited.

2.BP=110/70mmHg

3. neck veins examination= not engorged, elevated jvp with larger "a" component, hepato-jugular reflex didnot elicit.

4.examination of heart-

-inspection-

(precordial area)shape normal,

 apical impulse not seen,

 no engorged superficial veins

 no polythelia, 

no scar mark present

(beyond precordium)-no pulsations seen in other areas, 

back-slight kypohosis present

-palpation:

a.mitral area:

-apex beat=changed, down and outward (in 6th intercostal space, in anterior axillary line)

-no thrills present

b.pulmonary area=normal

c.aortic area=normal

d.tricuspid area=loud S1 felt, no thrills

-no palpable pericardial rub,no tracheal tug.

IV.auscultation:

a.cardiac rate=72bpm,

b.irregularly irregular rhythm, 

c.mitral area=loud S1, 

d.tricuspid-loud S1

e.pulmonary area=splitting of S2-loud P2 component.

Based on the above findings, following investigations were sent

1.RFT

2.hemogram

3.CUE

4.CXR

5.ECG

-irregular rhythm, absent p waves, right axis deviation, 

-ST elevation in V4 V5 aVR

Cardiomegaly, enlargement of rt atrium, rt ventricle, Lt ventricle

-calcified mitral valves

-fish mouth appearance 

based on the above investigations, the provisional diagnosis is MITRAL STENOSIS with HEART FAILURE.

TREATMENT:

1.INJ.LASIX 2amp in 50ml NS @8mg/hr

2.oxygenation to maintain spO2 above 95%

3.nebulization with budecort 12th hourly

4.strict I/O charting

5.monitoring BP,PR hourly

6.fluid and salt restriction

7.head end elevation

8.inj.amiodarone 300mg (2amp) at 6ml/hr

9.inj.pantop 40mg/OD/iv

10.T. ecosprin 75mg/PO/OD

(some insight in the case's history= patient was a agricultural labourer 5 years ago, mostly into plantation in paddy fields, occasionally did labour of carrying the harvest, which eventually caused her weakness and she had to quit!)