35 years old male, shortness of breath
Hi, I Shivraj Sontakke 3 rd semester medical student.
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.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.CHIEF COMPLAINTS
A 35 year old who is painter by occupation came with chief complaints of shortness of breath and fever since 1 weeks
History of present illness
Patient was apparently asymptomatic 1 week back, then he developed
• shortness of breath on exertion, since 1 week.
• high-grade fever since 1 week, more during night, relieved on medication and relapses back.
• decreased urine output since 1 week
• dragging type of pain in both legs and hands, associated with generalised weakness.
• orthopnea and PND present since 4 days
History of past illness
No history of DM, HTN, TB, Epilepsy, leprosy, CAD, CVN, Asthma or any other chronic illness.
No history of previous transfusion.
Personal history :
Built : Weakly nourished
Appetite : Decreased since 1 week
Diet : mixed
Sleep : Decreased since 1 week
Bladder movements:
Anuria since 1 day associated with burning micturition.
Bowel movements: regular
Addictions : toddy consumer in summer season.
Regular alcohol consumer, once a week.
No h/o smoking
Family history :
His wife was diagnosed with pulmonary TB, got admitted in hospital 1 month ago.
General examination :
Patient was coherent, cooperative and conscious. Well orientated to time and space.
Pallor : absent
Icterus : present
Clubbing: absent
Cyanosis : absent
Koilynochia: absent
Pedal edema : absent
Lymphadenopathy: absent.
Vitals
Systemic Examination :
Respiratory system examination
Inspection :
Shape and symmetry of chest : normal, symmetrical
Trachea : central
Respiratory movements: normal
Apical impulse: seen
Skin over the chest : normal
Dysnea : present
Palpation::
Trachea : central
Respiratory movements: normal
Fremitus : normal
Percussion
Normal
Auscultation
Breath sounds: vesicular
Adventitious sounds : absent
Vocal resonance: normal on both sides
Infrascapular crepts present
Other systems
CNS : No facial asymmetry, all reflexes are normal.
GIT : Tenderness present in hypochondrium, umblical and right lumbar region.
Liver and sleep not palpable.
Mild ascites.
CVS : Thrills , present
S1, S2 heard
No murmers.
Raised JVP.
Parasternal heave present Investigations
ECG findings : Biphasic T waves in V1 - V4
T wave inverted in II, III, avf.
Provisional diagnosis: Right ventricular failure with PAH , LIVER FAILU
Treatment: Conservative
