65F Heart failure with preserved ejection fraction , ITP

 A 65 years old female came to opd with c/o

breathlessness since one week, insidious onset gradually progressive, grade 2-3 nyha, aggrevated on exertion, relieved with rest

HOPI: 

Patient was apparently asymptomatic 10 days back then developed shortness of breath.

H/o generalized weakness and easy fatiguability 

No h/o chest pain, palpitations, syncope, orthopnea, pnd

No h/o cough, cold, fever, abdominal distension, facial puffiness, pedal edema, decreased urine output


Past history:

 h/o similar complaints in 2010, got 3prbc transfusions for Anemia, normal bone marrow biopsy, negative direct indirect coombs, in 2011 treated with steroids

K/C/O:

2mnths back got dental procedure done, associated with blood loss, and started on steroids

N/K/C/O : DM/ HTN /CAD / CVA / ASTHMA / THYROID /SEIZURE DISORDERS

Personal history : 


_ occupation : homemaker


Patient is married 


Patient takes mixed diet appetite is lost 


Bowel and bladder movements are regular


Micturition is normal 


No known allergies 


No addictions


GENERAL EXAMINATION : 

Patient is conscious, coherent , cooperative well oriented to time , place and person 


BP: 90/60mmHg

Spo2: 92% on ra

GRBs : 245 mg/dl

Pallor yes 

No icterus , cyanosis , clubbing , lymphadenopathy , pedal edema 

Dehydration present 


SYSTEMIC EXAMINATION : 

CVS : s1 , s2 heard , no murmurs , no thrills 

RS: Dyspnea present

Wheeze absent 

Position of trachea : central 

Vesicular breath sounds


P/A : 

Inspection : shape of abdomen : scaphoid 

Position of umbilicus : central and inverted 

No scars and sinuses present

All quadrants are moving equally with respiration

Palpation : 

No tenderness

No organomegaly 

Auscultation: 

Bowel sounds heard


CNS EXAMINATION: NFD

Higher mental functions : 

Conscious , coherent, cooperative 

MMSE normal 

Speech : normal 

Behaviour : normal 

Memory : normal 

Intelligence : normal 

Lobar functions : normal 

Signs of meningeal irritation : 

Neck stiffness : no

Keening sign : no

Cranial nerves , motor system , sensory system : normal 

Glasgow scale : E4V1M6

Deep tendon reflexes : Right . Left 

Biceps  2+

Triceps 2+

Supinator 1+

Knee 2+

Ankle 1+


CEREBRAL SIGNS 

Finger nose incoordination yes

Knee heel Incoordination yes


GAIT normal

Musculoskeletal system normal 

Skin normal 

Examination of breast normal 

Examination of ent normal

Examination of head and neck  normal 

Examination of oral cavity and teeth normal 


PROVISIONAL DIAGNOSIS: 


Heart failure with preserved ejection fraction 

Secondary to bicytopenia

ITP 





INVESTIGATIONS : 
























Comments

Post a Comment

Popular posts from this blog

60 year old male with loss of consciousness

Image
 A 60 years old male patient came to casuality with loss of consciousness at 2 Am  HOPI :  Patient was apparently alright and asymptomatic 12 days and then he experienced slip and fall on 15/4/24 and was taken to government hospital there he was diagnosed as intertrochanteric hip fracture and then shifted to ot there they have undergone surgery . On 17/4/24 patient developed altered sensorium and is so irritable and for further four days he is under observation of doctors and the concerned doctors did not inform the accurate cause to the patient attenders and then he was discharged  After discharge patient was at home with same irritable condition and altered sensorium for four days and again on 24/4/24 he suddenly developed SOB and then the patient attenders  admitted him to hospital there he had undergone CT brain suggested age related changes and for SOB they followed conservative treatment and altered sensorium is present And on Saturday at 2 Am patient loss consciousness so they s
Read more

62 year old with pedal edema and facial puffiness since 3 days

Image
 Varsha Bandaru Roll no 07 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 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 diagnosis and treatment plan CASE : 65 year old female farmer by occupation from sreerampelli came to hospital on 7/6/23 with chief complaints of fever 20 days back and pedal edema with facial puffiness since 20 days  H
Read more