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case presentation



1601006009

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient 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 also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

A 45 year old gentlemen, from suryapet who owns a travels business , came to OPD with 

CHIEF COMPLAINTS :

Palpitations since  3 days

Shortness of breath since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 days back then developed palpitations  ,present at rest,fast ,paroxysmal in onset ,irregular  lasts for 15 minutes associated with shortness of breath.

Shortness of breath  since 3 days sudden in onset, progressed from grade 2 to grade 3 ,no aggravating factors, relieved spontaneously after 5 to 10 minutes 

No history of                                                                          -fatigue,                                                                                -Cough , hemoptysis,                                                          -dysphagia ,hoarseness of voice                                      -fever, sore throat                                                              - pain abdomen, vomitings

PAST HISTORY:

Patient had fever 2 months back and  went to a local  hospital in suryapet for which he was given some medication, after which he developed shortness of breath (grade 2 ), headache ,then he went to a hospital in Hyderabad where he was diagnosed to be having pneumonia and in course of treatment patient developed MI . Coronary angiogram and recanalisation was done and patient was  put on anticoagulants, antipalatelets and discharged in hemodynamically stable condition and completely normal after discharge until 3 days back.

History of diabetes and hypertension since 10 years  diagnosed on general health checkup for which he is on regular medication .

No history of  TB,hypothyroidism,hyperthyroidism,asthma ,epilepsy.

FAMILY HISTORY:

Mother has history of hypertension 

PERSONAL HISTORY:

Diet: mixed                                                                           Appetite:normal                                                                Bladder &  Bowel movements: regular                          Sleep : decreased since 20 days                                       Addictions: no addictions 

DRUG HISTORY:                                                                 Antihypertensives: Telvas 40mg since 10 years         Anti diabetics: tab metformin 500mg ,voglibose 0.2mg, glimeperide1mg                 Antiplatelets:aspirin, clopidogrel                                    Statins:atorvastatin

GENERAL EXAMINATION:

A 45 year old patient who is well built and well nourished is conscious ,coherent,cooperative and comfortably seated,well oriented to time,place and person




There are no signs of pallor,icterus,cyanosis,koilonychia,generalised lymphadenopathy and pedal edema.







JVP not elevated.



VITALS:

Temperature:afebrile

Pulse: 90 bpm,regular,normal volume

BP: 100/80 mm hg on right upper arm in sitting position


Respiratory rate : 16 cpm abdominothoracic


SYSTEMIC EXAMINATION:

CVS:

INSPECTION:

Shape of chest: normal



Trachea : central in position 

No precordial bulge 

Apex impulse visible in left 5th intercostal space medial to midclavicular line 

No  visible left parastsrnal heave, epigastric pulsations,2nd ICS pulsations

No other pulsations seen

No scars,sinuses or dilated veins seen on any part of thorax

PALPATION:

All inspection findings confirmed.

Trachea central in position.

Apex beat in left 5th ICS 1cm medial to midclavicular line





AUSCULTATION:

MITRAL AREA:

Two heart sounds heard.S1 and S2

TRICUSPID AREA:

Two heart sounds heard,S1 and S2 which are normal

AORTIC AREA:

Two heart sounds are heard. S1 and S2.

PULMONARY AREA:

Two heart sounds heard. S1 and S2.

CENTRAL NERVOUS SYSTEM:

No facial asymmetry ,all reflexes are normal .

RESPIRATORY SYSTEM:

Normal Vesicular breath sounds heard, no adventitious sounds heard.

GIT:

No hepatosplenomegaly, no ascites.


INVESTIGATIONS

- Indirect ophthalmoscopy for hypertensive retinopathy

-Thyroid function tests

-serum electrolytes  awaiting for results 

ECG:



Chest xray:


PROVISIONAL DIAGNOSIS:

- Secondary to cardiac causes                                         

?arrythmias

- Metabolic cause

?thyroid abnormality

- Neuro psychiatry cause

?anxiety



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This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent Here we discuss our individual patient 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 also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome. A 45 year old gentlemen ,from ramanapet who is farmer by occupation came to the OPD with CHIEF COMPLAINTS: B/l Pedal edema since 3 months  Shortness of breath since 2 months HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 months back then developed  pedal edema, insidious in onset, bilateral ,gradually progressive from involving ankles to limbs  (grade1to grade 3 ), pitting type ,aggravated   by walking and by end of the day,relieved by elevating leg, then developed shortness of breath w