THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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
8-08-2022
A 75 years old female came to the opd with chief complaints of
-chest pain since 3months.
-Shortness of breath since 3 months.
-B/L knee joint pain since 5 years( more of Right knee joint pain).
History of presenting illness:
She was apparently asymptomatic 20years back then she sustained left shoulder injury due to accidentally slipping at her home.
15year back she was hit with an axe on her forearm because of which she had laceration.
13years back she developed itching all over body( more of upper limbs) for which she went to hospital and diagnosed with diabetes.
One day 10year back she was feeling giddy and sustained right hip injury due to sudden fall for which she had surgery.
And at the same time she diagnosed with hypertension.
She injured her left hip in similar manner 5 years back for which she had a surgery.
Since then she had mild lower limb pain.
4 years back she accidentally fell on her right knee since then the knee pain is increased.
From 3 years she is using stick for the support to walk.
3months back she developed swelling over the left cheek region it went under the cheek spread to the other side of the face. Swelling is hard, red. For which she used home remedy but it didn’t subsided then she went to RMP she received some medication still it didn’t subsided then went to higher center where she received some injections for one month then the swelling became soft then the swelling is relieved with Incision and Drainage.
3months back she developed chest pain which was burning type and non radiating.
3months back she developed shortness of breath by walking some distance( Grade 3).
She also complains of tingling sensation of lower limb since 3 months.
Past history:
H/O right hip surgery 10 years back.
H/O left hip surgery 5 years back.
N/K/O Tuberculosis,Asthma,epilepsy,CAD.
Family history:
Not significant.
Personal history:
Diet : Mixed
Appetite :normal
Sleep : Adequate
Bowel and bladder moments :Regular
Addictions-none
General physical examination:
Patient is conscious,coherent, cooperative to time,place and person.moderately built and moderately nourished.
Pallor-absent
Icterus-absent
Cyanosis -absent
Clubbing-absent
Lymphadenopathy-absent
Systemic examination:
CVS- S1 S2 heard
Apex beat felt in 5th intercostal region and lateralized.
Ejection systolic murmer heard.
RS-Barrel shaped chest
BAE+
Fine crepitations in right infra axillary area.
CNS- NFND
P/A-soft, non tenderness
https://youtube.com/shorts/s1Z3ftoLHoU?feature=share
Investigations
USG
Chest X ray
Provisional diagnosis:
Heart failure with diabetes and hypertension.
Osteoarthritis of knees
Treatment:
Tab LASIX 20mg PO BD
Tab MVT PO OD
Tab RANTAC 75 mg PO BD
Tab ULTRACET 1/2 tab QID
MONITOR BP AND GRBS every 4th hourly.
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