55/F with HFrEF 2° to CAD with Type 2 PAH, HTN(since 2 years) , DM(5yrs) , CAD(10yrs)

 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've 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 a diagnosis and treatment plan.

CASE

This is a case of a 55 year old female who presented with a complaints of diminished vision since 1 year.

History Of Presenting illness:

Patient was apparently alright until 10 years ago, then she had complaints of dry cough and S.O.B  for which she went to a local hospital and was diagnosed with CAD 

Patient is a known case of CAD since 10 years

Pt  alos  complains of decreased urine output since one year. 

Patient has a history of pleural effusion 1 year ago, which was treated conservatively.

Complaints of excertional dyspnea, PND present, shortness of breath grade 3. 

Patient had no complaints of fever, Pain in abdomen, vomiting, loose stools, burning micturition , cold ,cough.

Patient has a history of bilateral pedal edema extending upto knee on and off since 10 years. 

History of Past illness:

Patient is known case of

CAD since 10years

 diabetes mellitus since 5 years 

Hypertension since 2 years

Personal history-

Diet- mixed

Appetite- decreased

Seep- adequate

Bowel (constipated) and bladder regular

No Addictions

Family history

Not significant

Allergic history

No known allergies

General physical examination

Patient is C/C/C.

Pallor : no

Icterus: No

Cyanosis :no

Clubbing of fingers/toes : Yes

Lymphadenopathy : No 

Edema of feet : No

Malnutrition : No

Temp. : 97.2 F

P.R. : 86 bpm

R.R. : 16 cpm

B.P. : 100/70 mmhg

SYSTEMIC EXAMINATION

CVS 

Cardiac sounds      :- S1 & S2 - Present

Para sternal heave present

S3 gallop sound 

Apex at 6th intercostal space

RESP. SYSTEM

BAE+ , NVBS , NO ADDED SOUNDS

ABDOMEN

Soft, Non-tender 

C.N.S:- N.F.N.D

Glasgow Scale - 15/15

INVESTIGATIONS:-

CXR

ECG

2d Echo