General medicine Internship Real patient OSCE towards optimising clinical complexity

This online E-log Entry Blog is an objectively structured clinical examination method to assess the clinical competence during the course of my General Medicine Internship rotation (June'2023-August'2023) by reviewing the case reports shared below and to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs for questions surrounding the clinical vignettes borrowed from the E Log Book.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Case report :

A 41 YEAR OLD FEMALE, HOUSEWIFE BY OCCUPATION CAME TO THE CASUALTY WITH COMPLAINS OF FEVER AND PAIN ABDOMEN SINCE 2 MONTHS. 

http://sreelekhatondapuelog.blogspot.com/2023/06/41-year-old-female-with-pain-abdomen.html

1.What were the risk factors of the patient's ascending urinary tract infection? 

2. What are the measures that can be taken to prevent pyelonephritis post gynecological surgeries? 

3. What is the most specific imaging method for the diagnosis of renal abscess? 

4. What are the other treatment modalities for the treatment of renal abscess? 

43 YEAR OLD MALE WITH SEIZURES

This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.

Name: Sreelekha tondapu 

Roll no. - 156

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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are 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

43 YEAR OLD MALE WITH SEIZURES

A 43 year old male was brought to the casualty with comlains of involuntary movements of body since today morning. 

HISTORY OF PRESENTING ILLNESS: 

The Patient was apparently asymptomatic 4 days back when he had a binge of alcohol . he lost consciousness at his workplace and was taken to the hospital. At the hospital, the correction fluids were given and the patient was sent home. Today morning he had 2 episodes of involuntary movement of body (tonic movements with stiffening of body) lasting 1-2 minutes and relieved on itself. 

His wife checked his grbs at home after this episode and it was found to be 60mg/dl after which he was rushed to the hospital. In the hospital the correction was done inspite of which involuntary movements continued. He was then brought to our hospital. 

No uprolling of eyes or loss of consciousness during the episodes.

No c/o vomitings, headache, frothing from mouth, deviation of mouth, tongue bite, post ictal confusion, involuntary micturition/defecation.

PAST HISTORY:

No similar complains in the past.

K/C/O DM-II since 5 years on insulin. He was diagnosed with DM-II Incidently during an episode of fever for which he was initially prescribed OHA'S. The patient used to skip taking his medication. Due non compliance and very high sugars he was then shifted to insulin. 

N/k/c/o HTN, CVA, CAD, Bronchial asthma, thyroid disorders. 

DAILY ROUTINE :

The patient works as an attender in a college.

He lives with his wife and three children.

He doesn't always follow his routine and go to the college.

He gets up in the morning and freshens up and has breakfast. After his family leaves for work/college, he either goes to college or goes out with his friends and drinks alcohol. 

He often skips meals  as he forgets about them while he is drinking alcohol. He often consumes food late at night when he is very hungry. 

The alcohol consumption has increased in the last 1 year. 

On enquiring about the reason of chronic alcoholism with his family, they say that they can't think of any triggers as such. 

PERSONAL HISTORY

Diet: mixed 

Appetite: lost

Sleep: adequate 

Bowel: regular 

Micturition: normal 

Addictions: drinks alcohol since 20 years, chews gutka since 1 year 

Allergies: nil

Family history: not significant

GENERAL EXAMINATION

Patient is examined in a well lit room after taking an informed consent. 

Patient is conscious and coherent. 

No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema 

VITAL AT THE TIME OF ADMISSION: (09/07/23) 

Temp: 98F

Pulse: 114bpm

RR: 20cpm

Bp:100/80 mm of hg 

Spo2: 99% at RA

Grbs: 

Systemic examination:

CNS EXAMINATION: 

GCS: 15/15

The patient is conscious. 

Speech: normal

Cranial nerves: intact 

Seonsory system: normal 

Motor system: 

                       UL                       LL

Tone R INCREASED       INCREASED

          L INCREASED       INCREASED

POWER

          R      5/5                        5/5

          L       5/5                        5/5

REFLEXES           R                       L

BICEPS               2+                      2+

TRICEPS             1+                      1+

SUPINATOR        0                         0

KNEE                    0                         0

ANKLE                  0                         0

PLANTAR             E                         E

RESPIRATORY SYSTEM EXAMINATION 

-Bilateral air entry is present, normal vesicular breath sounds heard. 

CARDIO VASCULAR SYSTEM

S1 and S2 are heard. No murmurs are heard

ABDOMINAL EXAMINATION:

Soft, non-tender. 

No organomegaly

Bowel sounds are heard. 

PROVISIONAL DIAGNOSIS: SEIZURES UNDER EVALUATION SECONDARY TO ? HYPOGLYCEMIA ? TOXIN MEDIATED

INVESTIGATIONS: 

9/07/23

SERUM ELECTROLYTES: 

Na: 145

K: 3.2*

Cl: 99

Ca2+: 1.13

Mg2+: 2

Blood urea 20mg/dl

S. Creatinine: 1 mg/dl

RBS: 130MG/DL

LFT:

total billirubin : 0.98mg/dL

Direct bilirubin: 0.20 mg/dL

AST: 45 IU/L

ALT: 30IU/L

ALP: 301* IU/L

Total proteins: 7 gm/dL

Albumin: 4 gm/dL

A/G ratio: 1.25

Hemogram:

Hb: 10.9gm/dL*

Total count: 6,400cell/mm3*

N/L/E/M/B: 75/18*/2/5/0

PCV: 34.6 vol%*

MCV: 78.6fl*

MCH: 24.8pg*

MCHC: 31.5%

RDW-CV:18.2%*

RBC COUNT: 4.40 millions/mm3*

PLATELET COUNT: 1.92lakhs/mm3

Smear

RBC: normocytic normochromic 

TREATMENT GIVEN: 

INJ. LORAZEPAM 2CC IV/STASTAT

INJ. LEVIPIL 1GM IN 100ML NS IV/STAT

INJ. SODIUM VALPROATE 300MG IN 100ML NS IV/BD

INJ. HAI S/C ACCORDING TO GRBS

INJ. THIAMINE 1AMP IN 100ML NS IV/BD

SYP. POTCLOR 15ml IN 1 GLASS OF WATER

10/7/23

FBS: 192 MG/DL

PLBS: 294 MG/DL

HBA1c: 6.5%

HEMOGRAM

Hb: 9.7gm/dL*

Total count: 7,800 cell/mm3*

N/L/E/M/B: 70/20*/4/6/0

PCV: 30.2 vol%*

MCV: 70.8FL*

MCH: 25.1pg*

MCHC: 32.1%

RDW-CV:18.2%*

RBC COUNT: 3.8millions/mm3*

PLATELET COUNT: 2lakhs/mm3

Smear

RBC: normocytic normochromic 

SERUM ELECTROLYTES: 

Na: 139

K: 3.5*

Cl: 101

Ca2+: 1.24

11/7/23

USG ABDOMEN: 

B/L RAISED ECHOGENECITY OF THE KIDNEY. 

41 YEAR OLD FEMALE WITH PAIN ABDOMEN AND FEVER

This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.

Name: Sreelekha tondapu 

Roll no. - 156

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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are 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.

A 41 year old patient came to the casualty with 

CHIEF COMPLAINTS:

1. Pain abdomen since 2 months 

2. Fever since 2 months 

HISTORY OF PRESENTING ILLNESS:

Patient came to the casualty with complains of pain abdomen since five days 

The patient was apparently asymptomatic 2 years back when she had white discharge PV for which she took medication but it did not resolve. She had a surgery (hysterectomy) for the same on April 26 2023.

Since then the patient was having on and off episodes of pain abdomen which was of squeezing type and diffuse. It was relieved on taking medication (unknown)

Since five days, the intensity of pain has increased. The pain in the hypogastric region and is of squeezing type. She also complains of pain in the left lower back region which is of squeezing type and radiates towards the groin.

It is associated with vomitings (2 to 3 episodes per day, non-projectile, non-bilious, watery with food particles as contents.)

The patient also complains of fever on and off since two months which is of low grade, intermittent and is associated with chills and rigours and reduced on taking medication (paracetamol 650mg PO/BD)

The patient complains of burning micturition since 2 months. 

No Complains of decreased urine output.

PAST HISTORY :

- Patient was diagnosed with DM2 four days back and not put on any medication

- Not a known case of HYPERTENSION, TUBERCULOSIS, CVA, CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.

MENSTRUAL HISTORY

Past: attained menarche at 12 years

3/30, 2-3 pads/day

Present: 

Hysterectomy done on April 26/04/23

Marital history:

Age of marriage: 15 years 

Non consanguineous marriage. 

Obstetric history:

P2A2L1D1:

A1: Spontaneous abortion at 5 months 

D1: still born 

A2: elective abortion done at 4 months dur to severe IUGR

L1: 9years, Female, 3 kgs at birth, NVD, Alive and healthy

PERSONAL HISTORY

Diet: mixed 

Sleep: adequate 

Bowel and bladder: regular 

Addictions: the patient drinks toddy during festivals 

Allergies: nil

Family history: not significant

GENERAL EXAMINATION

Patient is examined in a well lit room after taking an informed consent.

She is conscious, coherent and cooperative;

Pallor present. 

Bilateral pitting type of pedal edema present 

No signs of icterus, clubbing, cyanosis, generalized lymphadenopathy. 

VITAL AT THE TIME OF ADMISSION: (24/06/23) 

BP: 160/90 mm of hg

PR: 121 bpm

RR: 24cpm 

Spo2: 99% at RA 

Systemic examination:

ABDOMINAL EXAMINATION:

On inspection:

-Truncal obesity is seen. 

-Umbilicus is central and inverted. 

- well healed transverse scar is seen on the lower abdomen. 

-There are no visible pulsations, peristalsis, sinuses or engorged veins. 

PALPATION: 

-There is no local raise of temperature 

-Tenderness is present over the hypogastric region. 

- left renal angle tenderness present 

- Abdomen is soft 

-No organomegaly. 

AUSCULTATION:

Bowel sounds are heard. 

RESPIRATORY SYSTEM EXAMINATION 

-Bilateral air entry is present 

- decreased breath sounds in ISA and IAA

CNS EXAMINATION: 

No functional deficits 

CARDIO VASCULAR SYSTEM

S1 and S2 are heard. No murmurs are heard

Provisional diagnosis:

 Acute left pyelonephritis with lower pole abscess of left kidney with ?LRTI with normocytic normochromic anaemia with De novo DM II

INVESTIGATIONS DONE PRIOR TO ADMISSION

INVESTIGATIONS 24/06/23

RBS: 101 mg/dl

Serum urea: 15 mg/dL

Serum Creatinine: 0.8 mg/dL

Serum electrolytes

Na+: 136 mEq/L

K+: 2.9 mEq/L

Cl-: 102 mEq/L

Ca2+ (ionized) : 1.09 mmol/L

Urine electrolytes

Na+: 126 mEq/L

K+: 6.9 mEq/L

Cl-: 139 mEq/L

LFT

total billirubin : 0.58 mg/dL

Direct bilirubin: 0.15 mg/dL

AST: 29 IU/L

ALT: 16 IU/L

ALP: 297* IU/L

Total proteins: 4.6 gm/dL

Albumin: 1.7gm/dL

A/G ratio: 0.57

PT: 17

INR: 1.25 

APTT: 35

Hemogram:

Hb: 7.5gm/dL*

Total count: 12,500 cell/mm3*

N/L*/E/M/B: 80/15*/3/2/0

PCV: 22.2vol%*

MCV: 71.6fl*

MCH: 24.2pg*

MCHC: 33.8%

RDW-CV:14.8 %*

RBC COUNT: 3.1 millions/mm3*

PLATELET COUNT: 2.4 lakhs/mm3

Smear

RBC: normocytic Normochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

Serology : negative 

CUE: 

Albumin: +

Sugars: nil 

Bile salts/ bile pigments : nil

Pus cells: 2-3 cells /hpf

Epithelial cells: 2-3 cells/hpf

No crystals, casts, red blood cells. 

Urine for ketone bodies: negative 

USG ABDOMEN AND PELVIS:

FINDINGS: 

1. Evidence of bulky and altered echotexture of left kidney with perinephric fluid

2. Evidence of 42*35mm hypoechoic area noted in lower pole of left kidney with no internal vascularity (? Abscess) 

IMPRESSION:

Left pyelonephritis with abscess in the lower pole of the kidney

Chest x-ray PA view

ECG: 

2D ECHO:

Treatment given: (24/06/23) 

 1. IVF NS @ 75ml/hr

 2. INJ. PIPTAZ 4.5g IV/TID

 3. INJ. PAN 40MG IV/OD (BBF)

 4. INJ. BUSCOPAN 1AMP IM/SOS

 5. INJ. TRAMADOL  1AMP IN 100ML NS IV/SOS

 6. INJ. ZOFER IV/SOS

 7. INJ. NEOMAL 1G IV/SOS

 8. OXYGEN SUPPORT TO MAINTAIN SATURATION ABOVE 95%

25/06/23

Hemogram:

Hb: 7.9 gm/dL*

Total count: 12,000 cell/mm3*

N/L*/E/M/B: 80/16*/1/9/0

PCV: 23.3vol%*

MCV: 71.3fl*

MCH: 24.2pg*

MCHC: 33.9%

RDW-CV:15.4%*

RBC COUNT: 3.27 millions/mm3*

PLATELET COUNT: 3.15lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

USG CHEST

FINDINGS: 

-E/o air bronchograms seen in B/L visualized lungs feilds. 

- E/o minimal free fluid Noted in left pleural space with underlying lung collapse. 

- right pleural space normal

- No underlying lung collapse on the right side

IMPRESSION:

- B/L air bronchograms in B/L visualized lungs fields. - S/O consolidatory changes. 

- Left minimal pleural effusion with underlying lung collapse 

Reticulocyte count: 0.5%

Serum electrolytes

 Na+: 133 mEq/L

K+: 2.8 mEq/L

Cl-: 98 mEq/L

Ca2+ (ionized) : 1.10mmol/L

26/06/23

Serum electrolytes

 Na+: 135 mEq/L

K+: 3.2 mEq/L

Cl-: 103 mEq/L

Ca2+ (ionized) : 1.14 mmol/L

Hemogram:

Hb: 7.9 gm/dL*

Total count: 12,000 cell/mm3*

N/L*/E/M/B: 80/16*/1/9/0

PCV: 23.3vol%*

MCV: 71.3fl*

MCH: 24.2pg*

MCHC: 33.9%

RDW-CV:15.4%*

RBC COUNT: 3.27 millions/mm3*

PLATELET COUNT: 3.15lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

HbA1c: 6.9%

Stool for occult blood : negative 

Serum ferritin: 

Review USG I/V/O liquefaction status of the abscess:

-e/o 60*36mm hypoechoic collection noted in the lower pole of the left kidney with 30-40% liquefaction status with internal echoes and septations

- e/o mild perinephric collection and peri nephric fat stranding. 

Left kidney -12. 2*6.5 cms (increased size and altered echotexture) 

IMPRESSION:

Left pyelonephritis with abscess in the left lower pole with 30-40% liquefaction status. 

Treatment given : 

 1. IVF NS, RL @ 75ml/hr

 2. INJ. PIPTAZ 4.5g IV/TID

 3. INJ. PAN 40MG IV/OD (BBF)

 4. INJ. BUSCOPAN 1AMP IM/SOS

 5. INJ. TRAMADOL 1AMP IN 100ML NS IV/SOS

 6. INJ. ZOFER 4MG IV/SOS

 7. INJ. NEOMAL 1G IV/SOS (IF TEMP> 101F) 

 8. INJ. HAI S/C ACC TO GRBS 

9. SYP. POTCHLOR 15ML PO/BD 

27/06/23

INVESTIGATIONS

Hemogram:

Hb: 8gm/dL*

Total count: 12,700 cell/mm3*

N/L/E/M/B: 75/16*/2/7/0

PCV: 24.6vol%*

MCV: 75.5fl*

MCH: 24.6pg*

MCHC: 33.8%

RDW-CV:17.2%*

RBC COUNT: 3.25 millions/mm3*

PLATELET COUNT: 3.43 lakhs/mm3

Smear

RBC: microcytic hypochromic

WBC: leukocytosis

Platelets: adequate in number and distribution

HEMOPARASITES: no hemoparasites seen

IMPRESSION: microcytic hypochromic anemia

Serum urea: 18 mg/dL

Serum Creatinine: 0.8 mg/dL

Serum electrolytes

Na+: 134mEq/L

K+: 4.3mEq/L

Cl-: 104mEq/L

Ca2+ (ionized) : 1.03 mmol/L

URINE C/S

Treatment 

 1.IVF NS, RL @ 75ml/hr

 2. INJ. PIPTAZ 4.5g IV/TID

 3. INJ. PAN 40MG IV/OD (BBF)

 4. INJ. BUSCOPAN 1AMP IM/SOS

 5. INJ. TRAMADOL 1AMP IN 100ML NS IV/SOS

 6. INJ. ZOFER 4MG IV/BD

 7. INJ. NEOMAL 1G IV/SOS (IF TEMP> 101F) 

 8. INJ. HAI S/C TID BEFORE MEALS ACC TO GRBS 

9. SYP. POTCHLOR 15ML PO/BD 

SHORT CASE - A 25 year old with abdominal pain

 

Hall ticket no. 1701006183

This is 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 centred 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 diagnosis and treatment plan.

A 25 year old male patient, a painter by occupation and a resident of nalagonda came with the chief complains of 

Pain abdomen since 5 days. 

HISTORY OF PRESENTING ILLNESS

The patient started consuming alcohol 5 year back due to peer pressure. Initially he used to consume 90ml of brandy every day which has now increased to 180ml everyday. Which he consumes half in the morning and half in the evening before going to sleep. 

The patient started smoking 2 years back. He smokes 5 beedis per day. 

The patient was apparently asymptotic 3 months back when he had abdominal pain which was towards the left upper side of the abdomen.  It was insidious in onset and was of dragging type.  He was admitted in a hospital was a diagnosed with acute pancreatitis and was treated for the same but was inadequate. 

During this visit to the hospital he was advised to stop alcohol consumption. 

As suggested by the doctor the patient stopped consuming alcohol and experienced withdrawal symptoms like tremors, irritability, aggressive behaviour. He had cravings to consume alcohol. 

6 days ago there was a fight between his wife and his mother due to which he consumed alcohol (180ml brandy) 

He was then brought to the hospital with the symptoms of pain in the upper left abdominal region. The pain was of squeezing type and we relieved on bending forward and aggravated on eating food. He also has 3 episodes of vomiting. The vomitus was small in quantity watery in consistency and green in colour and did not have any food particles. 

He did not complain of fever, chest pain, shortness of breath or constipation 

PAST HISTORY 

He had a similar episode 3 months back 

He is not a known case of diabetes mellitus, hypertension, epilepsy, bronchial Asthma. 

PERSONAL HISTORY 

Diet - Mixed

Appetite - Decreased (he has been eating only curd rice and drinking fruit juices since 3 months)

Bowel and Bladder- Regular.

Sleep - Disturbed and inadequate 

No known drug/food allergies 

FAMILY HISTORY 

Insignificant 

GENERAL EXAMINATION 

Patient was examined after a well informed consent in a well lit room 

The patient is conscious, coherent and cooperative and well oriented to time place and person. 

He is Poorly built and nourished. 

He has pallor 

There are no signs of icterus, cyanosis, clubbing, generalised lymphadenopathy and edema 

VITALS

Temperature- 98.7°F

Pulse rate- 90bpm

Blood pressure-120/80mmHg

Respiratory rate- 16cpm

SYSTEMIC EXAMINATION : 

ABDOMINAL EXAMINATION:

INSPECTION: 

Shape of the abdomen- scaphoid 

Umbilicus is central and inverted. 

There are no visible pulsations, peristalsis, scars, sinuses or engorged veins. 

PALPATION: 

There is no local raise of temperature 

Tenderness is present over the epigastrium and the left hypochondriac region. 

No organomegaly. 

PERCUSSION: 

Resonant - no free fluid present 

AUSCULTATION:

Bowel sounds are heard. 

RESPIRATORY SYSTEM EXAMINATION 

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

CNS EXAMINATION: 

No functional deficits 

CARDIO VASCULAR SYSTEM EXAMINATION 

S1 and S2 are heard. No murmurs are heard. 

INVESTIGATIONS:

Serum lipase - 112 IU/L

Serum amylase - 225 IU/L

USG ABDOMEN : 

findings- 5.1*2.8cms well defined anechoic cystic lesion is noted involving the body of the pancreas without internal vascularity (mostly pseudocyst) 

Impression- collection noted involving body of pancreas. Likely pseudocyst. 

COMPLETE BLOOD PICTURE:

RENAL FUNCTION TESTS:

LIVER FUNCTION TESTS

PROVISIONAL DIAGNOSIS:

Pseudocyst of pancreas secondary to unresolved secondary acute pancreatitis with alcohol withdrawal symptoms. 

Treatment 

1. Nil per oral (NPO)
2. IV fluids RINGER LACTATE ,Normal saline 100 ml per hour
3. Inj. TRAMADOL 100mg in 100ml NS IV BD
4. Inj. PANTOP 40 mg IV OD
5. Inj. OPTINEURIN 1 ampoule in 100ml NS IV OD
6. Tab. Lorazepam 2mg BD 
7. Tab. Benzothiamine 100mg OD

LONG CASE- A 35 year old with shortness of breath and palpitations

Hall ticket no. 1701006183

 This is 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 centred 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 diagnosis and treatment plan.

A 35 year old male patient, bartender by occupation and a resident of sathepally presented to the OPD with the chief complaints of 

1. Shortness of breath since 1 month
2. Palpitations since 7 days 
3. Pedal oedema since 2 days 
4. Cough since 2 days. 

HISTORY OF PRESENTING ILLNESS : 

The patient was apparently asymptomatic 1 month back when he started having shortness of breath which was initially of grade 2 (NYHA classification) - slight limitation of activity -ordinary activity results in fatigue. Which aggravated to grade 3 (marked limitation of physical activity- less than ordinary activity causes dyspnea) 10 days ago.  

It later progressed to grade 4 (dyspnea at rest) 

7 days ago.

The shortness of breath was aggravated on lying down and was relieved on sitting upright 

The shortness of breath was associated with palpitations since 7 days. 

He gives history of paroxysmal nocturnal dyspnea. During these episodes, once he wakes up he voluntarily stops himself from going back to sleep. 

He also complains of pedal edema since 2 days. It was of pitting type and it was up to the level of his ankle joint. 

There were no aggravating or relieving factors as such. 

The patient developed cough 2 days back. It is not associated with sputum. 

He doesn’t have any complains of excessive sweating, chest pain, chest tightness, fever, decreased urinary output. 

He gives a history of alcohol binge 8 days ago.  

PAST HISTORY: 

There are no similar complaints in the past. 

He is not a known case of diabetes mellitus, hypertension, epilepsy, bronchial Asthma. 

PERSONAL HISTORY 

Diet - Mixed

Appetite - Normal

Bowel and Bladder- Regular.

Sleep - Disturbed

No known drug/food allergies 

Addictions: he has consumed alcohol everyday since the age of 20 (15years). He drinks 90-180ml of brandy everyday. 

He is exposed to smoke as he works in a bar 

FAMILY HISTORY 

Insignificant 

GENERAL EXAMINATION 

Patient was examined after a well informed consent in a well lit room 

The patient is conscious, coherent and cooperative and well oriented to time place and person. 

He is Moderately built and nourished. 

There are no signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy 

He had pedal Edema upto his ankle joint. It was of pitting type. 

Truncal obesity is seen. 

VITALS:

Temperature: 98.6°F 

Respiratory rate: 18 cycles per minute 

Pulse rate : 160 beats per minute 

Blood pressure : 110/80 mm of Hg 

SYSTEMIC EXAMINATION:

CARDIO VASCULAR SYSTEM:

Inspection:

There are no  chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

RESPIRATORY SYSTEM EXAMINATION : 

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

CNS EXAMINATION: 

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

ABDOMINAL EXAMINATION:

There is no local raise of temperature. 

No tenderness 

The abdomen is soft

No organomegaly. 

No scars, sinuses, fistulas and engorged veins 

INVESTIGATIONS: 

Complete blood picture :

Hemoglobin - 12 gm%

TLC - 14,900 cells/cu.mm

 (Neutrophils- 89%)

PCV - 37.9%

RDW - 16.9%

MCV -70.9fl

MCH - 22.4pg

Platelet count - 2.84 lakhs/cu.mm

RBC - 5.36 million/cu.mm

Liver function tests : 

Total bilirubin - 2.32 mg/dl

Direct bilirubin - 0.02 mg/dl

SGPT - 58 IU/L

SGOT - 34 IU/L

ALP - 93 IU/L

Total protein- 6.9 g/dl

Albumin - 4.2 g/dl

Albumin / Globulin ratio - 1.5

Complete Urine Examination: Normal 

Serum creatinine: 1mg/dL 

Blood urea: 22mg/dL

Troponin I - 22.5ng/dL

ECG: 

2D ECHO: 

Report: moderate LV dysfunction (EF- 38%) 

              All chambers are dilated 

              No LV clots

X-ray 

PROVISIONAL  DIAGNOSIS:

Heart failure with dilated cardiomyopathy and atrial fibrillation 

Treatment: 

Tab. DILTIAZAM - 30mg PO BD

Tab. CORDARONE - PO BD

Inj. LASIX - 40mg IV TID 

Tab. ECOSPRIN - 150mg PO OD

Inj. CLEXANE - 60mg SC OD

Tab. CLOPITAB - 75mg PO OD.

Tab ATORVA - 50mg PO OD

Tab. AUGMENTIN - 65mg PO BD

Tab. AZITHROMYCIN - 500mg PO BD

Inj. THIAMINE - 20mg IV TID