AMISHA JAISWAL 03
70 Year old male patient elog
Amisha Jaiswal,MBBS
Roll no:03
June 23,2021
This is 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 patient’s clinical problems with collective current best evidence-based inputs. This is the E-log book also reflects my patient centred online learning portfolio and your valuable inputs on 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.
June 23,2021
Amisha Jaiswal,MBBS 8th semester
Roll no:03
This is 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 patient’s clinical problems with collective current best evidence-based inputs. This is the E-log book also reflects my patient centred online learning portfolio and your valuable inputs on 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.
A 70 year old male patient who is a farmer and a resident of choutuppal presented to the op with chief complaints of shortness of breath and swelling in legs since 6 days
History of present illness:
•8 months ago,
the patient experienced shortness of breath after being exposed to heavy rain and later had swollen legs and could not pass stools for 2days after which he had consulted the doctor.
•He was admitted in the hospital for 4 days and was referred to another doctor who had prescribed him the medications which he used for the past 7 months but the regularity in taking the medicine was not monitored
•2 days back, the patient came with similar complaints of swollen legs(was always present but aggravated since a week) and
•shortness of breath (since1 day) and weakness. Also complaints that the shortness of breath aggravated when he ate or performed any heavy work.
Past history:
1.patient had swelling in the scrotum since 5 years but had been ignoring it and has not taken any medications since onset
2. Surgery for the swollen scrotum has been denied by the doctors 1 month ago due to the condition of his heart
3. No H/O HTN,DM and epilepsy
Personal history:
Married
Diet: mixed
Appetite: lost
Sleep: adequate
Regular bowels
Normal micturition
No allergies
*H/O tobacco smoking till 6 years back i.e 2015
*Alcohol consumption is occasional and moderate
Family history:
No history of DM, HTN
Attender mentions that shortness of breath runs in the family [in patients mother and uncle(mothers brother)]
General examination
Patient is conscious, coherent, cooperative, oriented to time, place and person.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Edema present (pitting type)
Vitals
Afebrile
PR - 84bpm
BP - 100/60mm hg
RR - 60 com
SpO2 - 96% at room air
Systemic examination
CVS
No thrills
No murmur
Heart sounds S1 S2 heard
Respiratory
No dyspnea
No wheeze
Position of trachea - Central
Breath sounds - Vesicular
Abdomen
Shape - scaphoid
No tenderness
No palpable mass
Hernial orifices - Normal
No free fluid
No bruits
Liver - not palpable
Spleen - not palpable
Bowel sounds - Present
CNS
Patient is conscious, coherent
Response to speech
Provisional diagnosis
Heart failure
(Edema might suggest pooling of blood at lower extremities,
low contractility and less cardiac output of heart due to which there is less oxygen availability to tissues and hence shortness of breath is seen)
Plan of treatment
Conservative
Prognosis
Inadequate so far
Investigations:
Ultrasound report:
Clinical diagnosis
HFrEF ē Dcmp (heart failure with reduced ejection fraction )
(EF - 25%)
TREATMENT
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