A 70YRS OLD FEMALE WITH BREATHLESSNESS

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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. 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 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

A 70YRS OLD FEMALE FROM SURYAPET CAME TO OPD WITH CHIEF COMPLAINTS OF BREATHLESSNESS SINCE 3YRS , MORE SINCE 5 DAYS. 

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YRS AGO THEN SHE STARTED DEVELOPING BREATHLESSNESS WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE , AGGRAVATED SINCE 1 YR MORE SINCE LAST 5 DAYS , AGGRAVATED ON EXERTION AND RELIEVED ON REST ,NYHA GRADE II-III, ASSOCIATED WITH PALPITATIONS.

H/O COUGH OCCASIONALLY ON AND OFF DURING EPISODES OF BREATHLESSNESS.

NO H/O CHEST PAIN, ORTHOPNEA,PND, PEDAL EDEMA.

NO H/O DECREASED URINE OUTPUT.

NO H/O FEVER, PAIN ABDOMEN, BURNING MICTURITION.

PAST HISTORY:

K/C/O HYPERTENSION SINCE 4 YRS USED MEDICATION FOR 3 MONTHS AND THEN DISCONTINUED DUE TO POOR FINANCIAL STATUS.

NOT A K/C/O DM/CVA/CAD/ASTHMA/THYROID DISORDERS/ TB

PERSONAL HISTORY:

DIET: MIXED DIET     APPETITE: NORMAL 

BOWEL : REGULAR    MICTURITION: NORMAL

NO ADDICTIONS. 

FAMILY HISTORY:

NOT SIGNIFICANT.

GENERAL EXAMINATION: 

PATIENT IS CONSCIOUS , COHERENT,  COOPERATIVE. 

NO ICTERUS, PALLOR, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, PEDAL EDEMA. 

VITALS: 

 TEMP: 96.8F

 BP: 130/90

 PULSE RATE: 70BPM

 RESIRATORY RATE: 27CPM

SYSTEMIC EXAMINATION: 

CVS: S1 S2 HEARD, NO ADDED MURMURS

RS: DYSPNOEA, BAE+ ,NVBS HEARD.

P/A: SOFT, NON TENDER, NO DISTENSION, NO ORGANOMEGALY, BOWEL SOUNDS HEARD.

CNS: NO FOCAL NEUROLOGICAL DEFICIT.

PROVISIONAL DIAGNOSIS:

HEART FAILURE

INVESTIGATIONS:

2/7/24:

HEMOGRAM

HB: 10.3%

TLC: 11,800 cells/cumm

N/L/E/M: 54/39/00/07

PCV: 30.5

MCV: 78.6

MCH: 26.5

MCHC: 33.8

RBC: 3.88millions/cumm

PLATELETS: 2.47 lkhs/cumm

CUE

COLOR: pale yellow

APPEARANCE: clear

SP.GRAV: 1.010

ALBUMIN: trace

SUGARS: nil

BILE SALTS AND PIGMENTS: nil

PUS CELLS: 2-3

EPITHELIAL CELLS: 2-3

RBC: nil

others: nil

RFT

SR UREA: 61

SR CREATININE : 1.2

URIC ACID:4.5

SODIUM: 141

POTASSIUM: 3.6

CHLORIDE: 104

I CALCIUM: 1.18

LFT

TB:1.17mg/dl

DB:0.33mg/dl

AST:68 IU/L

ALT:95 IU/L

ALP:171 IU/L

TP: 6.1gm/dl

ALBUMIN: 3.81gm/dl

A/G RATIO: 1.66

LIPID PROFILE:

T CHOLESTEROL: 214mg/dl

TRIGLYCERIDES: 396 mg/dl

HDL: 42 mg/dl

LDL: 122 mg/dl

ECG:

2D ECHO: EF:41%

-MODERATE MR, MODERATE TR WITH PAH, TRIVIAL AR

-GLOBAL DYSKINESIA, NO AS/MS, SCLEROTIC AV

- MODERATE LV DYSFUNCTION

- GRADE I DIASTOLIC DYSFUNCTION, NO PE/LV CLOT. 

https://youtube.com/shorts/TfB1VH63__s?feature=shared

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https://youtube.com/shorts/dsRCnviIrco?feature=shared

DIAGNOSIS:

HEART FAILURE WITH MID RANGE EJECTION FRACTION(41%) .

TREATMENT:

INJ. LASIX 20mg IV/BD

TAB TELMA 40mg PO/OD

TAB MET- XL 12.5mg PO/OD

TAB PREGABA-M PO/OD

TAB ULTRACET PO/QID

DISCUSSION 

NYHA CLASSIFICATION:

I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath. II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain. III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain. IV Symptoms of heart failure at rest. Any physical activity causes further discomfort. EJECTION FRACTION HEART FAILURE: Ejection fraction (EF) is a measurement, expressed as a percentage, of how much blood the left ventricle pumps out with each contraction. An ejection fraction of 60 percent means that 60 percent of the total amount of blood in the left ventricle is pushed out with each heartbeat. A normal heart’s ejection fraction is between 55 and 70 percent. Heart failure with reduced ejection fraction (HFrEF), or systolic heart failure, is defined as left ventricular ejection fraction (LVEF) ≤ 40%. Heart failure with improved ejection fraction (HFimpEF) is defined as previous LVEF ≤ 40% with follow-up measurement > 40%. Heart failure with mildly reduced ejection fraction (HFmrEF) is defined as LVEF 41%-49% with evidence of provocable or spontaneous increased left ventricular filling pressures, such as increased natriuretic peptide or invasive/noninvasive hemodynamic measurement. Heart failure with preserved ejection fraction (HFpEF), or diastolic heart failure, is defined as LVEF ≥ 50% with evidence of provocable or spontaneous increased left ventricular filling pressures, such as increased natriuretic peptide or invasive/noninvasive hemodynamic measurement. Information taken from following articles : https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure https://www.heart.org/en/health-topics/heart-failure/diagnosing-heart-failure/ejection-fraction-heart-failure-measurement https://www.dynamed.com/condition/heart-failure-with-preserved-ejection-fraction-hfpef#GUID-C7D02B34-C808-4E5E-BE37-E7CF46B537EC