General Medicine Case 1

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August 10,2021

A 65 year old woman presented to the OPD for a regular checkup for shortness of breath.

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 6 months back,then she had shortness of breath along with the chest pain and there were no repeated episodes.

The patient is also suffering from backpain and pain in the back of the neck at the end of hairline for the past 5yrs.The pain is sharp and she's unable to bend due to this.

She also has continuous numbness in the last three toes of the left leg.

She has knee pain.

She has been suffering from radiating headache.

She also has iron defeciency anemia and constipation for the past 6months.

PAST HISTORY 

She had 3 vaginal deliveries and tubectomised 35 years back 

She was also diagnosed to be hypertensive and diabetic 12 years back on routine check up and has been using Tab Telma Beta 40/50mg, once daily along with Tab Metformin 500mg once daily past 12 years. 

Along with this she has be byen taking Tab Ultracet occasionally for her lower back pain along with a spinal brace for her lower back pain.  

Since the past 6 months she has also been on Tab Lasix 40mg, twice daily along with Tab Orofer XT, once daily. 

PERSONAL HISTORY 

She's experiencing loss of appetite past 6 months. She's on mixed diet. She also complains of Irregular Bowel and bladder movement and Inadequate sleep. 

FAMILY HISTORY 

No significant family history 

ON GENERAL EXAMINATION 

She was conscious, coherent and cooperative  

Pulse rate - 75 beats per minute

Blood pressure - 110/70mmhg

Respiratory Rate - 18 cycles per minute

Spo2 - 98% on Room Air 

GRBS - 150mg/dl

JVP - Not raised 

HEAD TO TOE GENERAL EXAMINATION 

Weight - 55 kgs

Thin built

Hair - Thin and graying 

Eyes - Pallor , No icterus

Nails - No clubbing, No Koilonychia 

No spinal deformities

Legs- No pedal edema 

SYSTEMIC EXAMINATION 

CVS:

Inspection: 

Shape of the chest - Ellipsoid 

Breast abnormalities - Absent  

Cutaneous lesions - Absent

No dilated veins, scars or visible pulsations 

 Palpation:  

Apex beat present in 6th ICS in Midclavicular line 

No palpable pulsations in aortic and Pulmonary areas

No palpable pulsations in sternoclavicular area

No left parasternal pulsations

No epigastric pulsations palpable 

RESPIRATORY SYSTEM:

Inspiratory crepts in right IAA and ISA 

PER ABDOMEN:

Soft

No tenderness 

No guarding, rigidity

Bowel sounds present 

CNS: Normal 

PROVISIONAL DIAGNOSIS 

Heart failure with reduced ejection fraction-29%

Iron deficiency anemia 

Known case of Diabetes mellitus and Hypertension since 12 years 

REPORTS 

ECG 

Chest X Ray PA view

COMPLETE BLOOD PICTURE 

Hemoglobin - 8.5 g/dl

TLC - 8000 cells/cumm

Platelets - 1.5 Lakhs/cumm

Peripheral smear - Anisopoikilocytosis with hypochromasia microcytes and pencil forms 

ABG 

Ph - 7.45

PCO2 - 35.5mmhg

PO2 - 92mmhg

HCO3 - 24.6 mmol/l 

COMPLETE URINE EXAMINATION 

No abnormalities present 

RENAL FUNCTIONAL TEST 

Serum creatine - 0.8mg/dl

Blood urea - 30mg/dl

Serum Sodium - 138 meq/l

Serum potassium - 4.5 meq/l

Serum Chloride- 100 meq/l 

LIVER FUNCTION TEST 

Total bilirubin - 0.46mg/dl

Direct bilirubin - 0.16 mg/dl

AST - 10 IU/L

ALT - 11 IU/L

ALP - 163 IU/L

Total proteins - 5.4 gm/dl

Albumin - 3.5 gm/dl

RBS - 157mg/dl

FBS - 137 mg/dl

PLBS - 264 mg/dl

HbA1c - 6.6 %

Reticulocyte count - 2%

Serum Ferritin - 12 ng/mL 

USG ABDOMEN

2D ECHO 

Global Hypokinesia, Mild LVH

Mild MR +, Trivial TR +/ AR+

Sclerotic AV

AML Doming

EF = 29% , RSVP = 29 mmhg

No PAH

Severe LV Dysfunction

Minimal PE

Diastolic Dysfunction +  

TREATMENT 

1. Tab Lasix 40mg/PO/BD

8am and 4pm

2. Tab Telma Beta 40/50mg PO/OD

8am

3. Tab Metformin 500mg/PO/OD

8am 

4. Tab Orofer XT/PO/BD

5. Tab Isosorbide Dinitrate 5mg/PO/BD for 3 days

6. Syrup Lactulose 10ml/PO/BD 

7. Fluid Restriction <1 Litre/day

8. Salt Restriction 2 grams/day 

9. Strict diabetic diet - was advised to follow Harvard plate.

FBS - 1