19 Lavanya blog spot . case study 2

                             

                  This is an 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 patient problem through series of inputs from available global online community of experts  with an aim to solve those patients clinical problem with collective current best evidence input 

                   This E blog also reflect my patient centered online learning portfolia and your valuable inputs on the comment box is welcome 
                 
                 I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history ,  clinical finding , investigation and come up with diagnosis and treatment plan .. 


                   50 yr old female , came to opd with c/oSOB{ Grade 2 -3 } since 3 days B/L Pedal edema since 8months {on &off } subsidding with medication & worsening since 1 week  


 Patient  was her usual self 15 yrs back then she had c/o SOB and was taken to hospital where angiogram was done an 7 yrs back mitral valve replacement was done .she was on regulation medication since then H/o B/L pedal edema piting type and H/o vomiting {2 to 3 episodes per day {on &off  since 8 months K/c/o DM SINCE 4 yrs H/o similar complaints in the past blood trasfussion done at the time of surgery {MVR}

  DIET : mixed 
APPITETIE : normal 
SLEEP : adequate 
BOWEL AND BLADDER MOVEMENTS : regular 
NO H/o burning micturition 
NO addictions 

general examimations :: 

patient is consious , coherent and cooperative 
moderatively built and nourished 
no pallor , icterus , cyanosis , and lymphadenopathy 
edema is present 

VITALS ::

Aferbile 
BP -130/80 mmHg 
PR 109 bpm 
RR36cpm 

SYSTEMIC EXAMINATIONS ::

B/L  Air entry present 
S1 S2 heard 
Apex beat at 6th ICS lateral to mild 
Clavicular line 
parasternal have present 
palpable p2 
JVP rasied 
DYspnea {grade 2 - grade 3 } 
 

INVESTIGATIONS DONE :: 

ECG , HEMOGRAM , PT 
APTT,CUE , RBS ,LFT , RFT 

POST OP MVR 7 YRS BACK 





TREATMENT:: 

FLUID RESTRICTION < 1 LT / DAY 
SALT RESTRICTION <2 grm/DAY 
INJ .LASIX 40 mg BD 
TAB ..MET-XL 25 mg BD 
TAB. ACITROM 1mg OD /PO 
TAB. ECOSPRIN 75 mgOD /PO 
BP/PR /TEMP ./ SPo2 montoring 
TAB. RAMIPRIL 2.5 mg OD/PO 
TAB . ATORVASTATIN 40 mg OD/PO

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