60 year old female patient

 

60 year old female patient 



GM Blog: 60 year old female patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 12-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of cold and cough since 6 days.
H/o fall on left shoulder 5days back.

Shortness of  breath since 5days.

HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 6 days back.then she had cold and cough which relieved on medication.  5 days back she fell down from bed while sleeping  at around 5am in morning.  From next day she complaints of breathlessness  which is grade 1 MMRC and progressed to grade 3 MMRC and pedal edema since 4 days. No h/ o fever and headache.   She complaints of left shoulder pain ( due to fall) . No h/ o chest pain ,palpitations, orthopnea, pnd.

Yesterday she went to area hospital around 9am and her bp was 185/120mmhg and then referred to our hospital. On admission her bp was 220/90mmhg.

PAST HISTORY:

M/k/c/o HTN,DM,TB,Astma, thyroid and epilepsy.

H/o fall from bed while sleeping 1 year back.

PERSONAL HISTORY:
Married 
Works at post office 
Diet: mixed. ( Non vegetarian)
Moderately built and nourishment.
Appetite - normal 
Bladder movement- normal
Bowel movements- normal 
Allergy-no 
Addiction- no


FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
She is well oriented to time, place and person. 
She is moderately built and nourished  
Pallor - present 
icterus absent
No cyanosis
No clubbing
pitting oedema ( bilateral pedal oedema) present ( grade 3)  
No Lymphadenopathy 

Vitals 

On admission 
PR: 98BPM
RR: 24Cycles per mon 
BP: 220/90 mmhg 
Temp: afebrile. 
Spo2: 98
Grbs: 193 mg percent 

Systemic examination: 
CVS: 
Thrills : no
S1 and S2 heard 
Cardiac murmurs absent

Respiratory system:
Dyspnea present
Position of trachea: central
Breath sounds: Vesicular 
Adventitious sound: rales ( crepts ) 1 rub 

Abdominal examination: 
Shape : obese 
Non tender
No palpable mass
Liver palpable
Spleen non palpable 

Central nervous system 
Conscious
Speech normal











Investigations 



Provisional diagnosis:
Acute left ventricular failure?  Ischemic heart disease? 

Treatment: 

Comments

Post a Comment

Popular posts from this blog

39 year old male patient from West Bengal

Image
This is a case of a 39 year old bus driver who is a resident of West Bengal. CHIEF COMPLAINT : Abdominal distension since 2 months. Swelling in the leg since 2 months. Decreased appetite since 2 months. Decreased urine output since 1 month.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type. After a month his urine output got decreased still he continued his work as a bus driver. His relatives started noticing that his abdomen is getting distended and his appetite is decreased. They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension
Read more

OSCE and Learning points

Image
OSCE AND LEARNING POINTS PREFINAL PRACTICAL EXAMS NAME : VAGISHA RANI ROLL NO: 138 DATE: 4 December '23 Blog link: https://vagisharani.blogspot.com/2023/12/48-year-old-male-patient-from-west.html QUESTIONS  1) West haven criteria clinical grade for hepatic encephalopathy. 2) Wilson's disease and cirrhosis of liver  Wilsons diease is an inborn errors of copper metabolism characterised by increased total body copper. Etiology: Molecular defect within the copper transporting ATPase encoded by gene ( ATP7B) located on chromosome 13 Pathology:  Copper enters the body through the digestive tract with the help of a transporter protein in the cells of the small bowel, copper membrane transporter 1 (Ctr1; SLC31A1).  In response to rising copper levels, an enzyme called ATP7A releases copper into the portal vein to the liver. Liver cells carry the CMT1 protein and metallothionein, and then ATOX1 binds it inside the cell. Once here, ATP7B links the copper to ceruloplasmin and
Read more

65 year old male

Image
65 year old male from beemanapally Date of admission 21/7/23 65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year.  History of present illness:   Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking. Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area. Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep.   Past illness: Diabetes since 15 years. Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness. History of Trauma 4 years back, then he had a fall while taking his cattle to the field due to which the patient experienc
Read more