A 65 year old with ATRIAL FIBRILLATION WITH HTN DM2 Heart failure anaemia with AKI

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

Case presentation 

Patient was brought to the casualty with a/h/o shortness of breath since 5 days and c/o b/l pedal edema since 5 years

HOPI - 

PT. WAS APPARENTLY ASYMPTOTIC 5 YEARS BACK THEN HE DEVELOPED PEDAL EDEMA BILATERALLY EXTENDING UPTO THIGHS , PROGRESSIVE IN NATURE, PITTING TYPE, RAISED LOCAL TEMPERATURE,SHINY SKIN . PT DEVELOPED SHORTNESS OF BREATH 5  DAYS BACK WHICH WAS AGGRAVATING ON WALKING, WITH NO RELIEVING FACTORS 

THERE IS NO H/O palpitations sweating, headache,giddiness ,

No H/o ORTHOPNEA ,PND,ABDOMINAL PAIN,BLEEDING MANIFESTATION 

PAST HISTORY 

KNOWN CASE OF DM2 HTN HYPOTHYROIDISM AND IS ON UNKNOWN MEDICATION SINCE FIVE YEARS

Personal history- APPETITE: NORMAL 

DIET: MIXED

SLEEP: ADEQUATE 

BOWEL: Normal , hard stools

BLADDER: NORMAL 

NO ALLERGIES 

ADDICTIONS - ALCOHOL 90ml twice or thrice in a month since 30 years

FAMILY HISTORY: 

NO H/O SIMILAR COMPLAINTS IN THE FAMILY 

General examination- 

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

OBESE  AND NOURISHED 

NO SIGNS OF PALLOR, ICTERUS  CYANOSIS, 

SIGNS OF CLULBBING of fingers , EDEMA of feet ( non pitting )   

VITALS: 

TEMP: 100 F

PR: 152 BPM 

RR: 34 CPM 

BP: 110/70 MM HG

SPO2: 96% @ 2% o2 

GRBS: 80 MG/DL 

CVS: S1, S2 HEARS, NO MURMURS 

RS: BAE+, NVBS 

TRACHEA: CENTRAL 

DYSPNOEA PRESENT  

NO WHEEZE 

NO RHONCHI 

ABDOMEN: NON  TENDER, SOFT, DISTENDED

LIVER AND SPLEEN NOT PALPABLE 

BOWEL SOUNDS HEARD 

FREE FLUID ABSENT 

CNS: 

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT 

SPEECH: SLURRED

NECK STIFFNESS ABSENT 

KERNINGS SIGN ABSENT 

CRANIAL NERVES: NORMAL 

MOTOR SYSTEM: NORMAL 

SENSORY SYSTEM: NORMAL 

GCS: 15/15 E4V5M6 

TONE: 

UL: NORMAL 

LL: NORMAL 

POWER: 

UL: BOTH 4/5

LL: BOTH 4/5

REFLEXES:             RT              LT

B:                           +2              +2

T:                           +2              +2

S:                           +1              +1

K:                           +2              +2

A:                           +2              +2

INVESTIGATIONS 

HB 8.7

TLC 6200

PCV 30.5

MCV 63.1

PLT 2.89

TB 1.30

DB 0.28

AST 51

ALT 16

UREA 48

CREATININE-  2.0 

NA- 120

K -4.2

Post dinner grbs - 83

2 am - 93

Pre bf - 145

2D ECHO 

TACHYCARDIA 

CONCENTRIC LVH

NO RWMA

MODERATE TR , MILD PAH, MILD MR, MILD AR

SCLEROTIC AV , THICKENED AV 

EF 55%

GOOD LV SYSTOLIC FUNCTION 

DIASTOLIC DYSFUNCTION, NO PAH

DIALATED R.A AND L.A

IVC SIZE  DIALATED NON COLLAPSING 

PROVISIONAL DIAGNOSIS 

ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE WITH DIALATED CARDIOMYOPATHY  HTN DM2 ,HEART FAILURE WITH ANAEMIA AND  AKI

TREATMENT 

TAB METAPROLOL POBD

INJ LASIX 40mg IVBD

INJ AMIADARONE 900MG IN 500ML NS @35ml/hr

INJ PAN 40mg po/od

INJ HAI( 6u-6u-6u)

INJ IRON SUCROSE

INJ HEPARIN

TAB DILTEAZAM

OSCE QUESTIONS 

1) WHAT IS THE PRECIPITATING FACTOR FOR ATRIAL FIBRILATION ?

Ans) THE PATIENT IS A KNOWN CASE OF HYPOTHYROIDISM AND ANAEMIA BOTH OF WHICH ARE A PRECIPITATING FACTOR FOR AF

2) WHAT ARE THE TRENDS OF HAEMOGLOBIN AND WHAT IS THE CAUSE OF SUDDEN DROP OF HAEMOGLOBIN

ANS)

HIS STOOL FOR OCCULT BLOOD CAME POSITIVE ON DAY 1 WHICH LEAD TO DROP IN HB

Q) WHAT IS THE INFERENCE OF THE 2d ECHO AND WHAT DO WE USE TO PREVENT THE EFFECT OF AF

 DIASTOLIC DYSFUNCTION WITH MID RANGE EF HF 

WE USE ASPIRIN AND CLOPIDOGREL TO PREVENT THROMBUS FORMATION 

WHAT WILL  YOU ADVISE THE PT ABOUT HIS TRUNCAL OBESITY 

ANS ) WE HAVE ADVISED HIM TO STRICTLY FOLLOW HIS DIABETIC DIET ie EATING NUTRITIOUS FOOD IN MODERATE AMOUNTS REDUCED MEALS WITH HIGH FATS AND SUGARS AND FOLLOW A STRICT TIME.