E log of medicine case

 NOTE :"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 patients clinical problems with collective current best evidence based inputs"

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 86 YEAR OLD MALE PATIENT CAME TO CASUALTY ON 18/10/21

CHIEF COMPLAINTS :

-shortness of breath

-orthopnea since 4 days 

-fever since 1 day 

History of present illness:

Patient was apparently assymptomatic 11 years back then he had a prick to his left foot and developed swelling and was taken to RMP and told that he has infection and then he  was brought to our hospital which was diagnosed with non healing ulcer after 1 week he was taken to Hyderabad for further evaluation and grafting was done and which was not successful and he got dressing regularly for next 6 months .

And for the next 6 years he didn't have any complaints, ulcer was healing acc to the attender .

2 years back patient had shortness of breath ( grade 4 ) associated with orthopnea ,was taken to Osmania hospital and was diagnosed with HFrEF with EF35% and was put on INJ LASIX and regular dressings was done for the next 2 years. 

From 4 days patient had not taken his regular medication 

History of past illness :

Not a K/C/O DM ,HTN ,ASTHMA, EPILEPSY

K/C/O COPD 

Unhealed ulcerated foyears. Surgery done to graft thigh muscle to the foot but has shown no improvement

TREATMENT HISTORY

• Thigh muscle graft to feet for non healing ulcer
• Has been regularly tested for DM and HTN.

PERSONAL HISTORY

• Appetite - lost

• Bowels- regular

• Micturition -normal

• No known allergies

• Quit alcohol and Cigarettes 8 years ago on recommendation by physician for non healing ulcer
• FAMILY HISTORY

• No significant family history

PHYSICAL EXAMINATION

1. GENERAL EXAMINATION :

• Weight - 45kgs

• Pallor - No

• Icterus - Yes 

• Cyanosis - No

• Clubbing of finger/toes - No

• Lymphadenopathy - No

• Oedema - Yes 

• Malnutrition - yes 

• Dehydration - No

• Koilonychia - No 

• Temperature - afebrile 

• Pulse rate -143 b/min

• Respiration rate - 41/min

• BP 100/70 mmHg 

• Large surgical scar along right thigh and unhealed ulcer on  right foot
• 
  
• Systemic examination :

CARDIOVASCULAR SYSTEM

• JVP seen 

• Apex beat at 6th ICS

• Cardiac sounds - S1 , S2 positive
• EF 42%
• 
  
• RESPIRATORY SYSTEM 

• Dysponea - Yes 

• Wheeze - Yes

• Position of trachea - Central 

• Breath sounds - Vesicular 

• Adventitious - Rhonchi

•  ABDOMEN

• Soft tender with bowel sounds heard

• Shape of abdomen - Normal
• CENTRAL NERVOUS SYSTEM 

• Level of consciousness 

1. Alert

2. Stuporous 

• Signs of meningeal irritation

1. Neck stiffness - no

2. Kerning’s sign - no

• Cranial nerves - normal 

• Motor system - normal

• Sensory system - normal 

• Glasgow system - normal 

• Cerebral signs

1. Finger nose coordination - Yes

2. Knee Heel In-coordination - Yes

   
   

.MUSCULO SKELETAL SYSTEM - normal 

Investigations :

Chest x Ray :

2 d  echo report :

Complete urine examination :

LFT:

Hemogram:

Provisional diagnosis:

HFrEF with EF 45% with COPD with Non healing ulcer of left foot

Treatment 

1.)Head end elevation upto 30° 

2.)Fuild restriction upto 1 lit / day 

3.)Salt restriction < 2.5 g/ day 

4.)Inj Neomol 100 ML IV / if temp > 101° F 

5.)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly 

6.)Inj pantop 40 MG /IV /OD 

7.)Tab carvidelol 1.25 mg / po/od 

8.)Inj Hydrocortisone 100 mg / iv stat 

9.)Inj lasix 10 ampules ( 200 mg ) in 30 ml NS at 2 ml / hr 

10.)Dressing for Left LL ulcer 

11) Moniter vitals