35 year old male patient with dilated cardiomyopathy associated with atrial fibrillation

FINAL EXAMINATION:LONG CASE

HALL TICKET NO. 1701006112

This is an 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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments 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 a diagnosis and treatment plan.



CHIEF COMPLAINTS

* Shortness of breath since 10 days 
* Palpitations since 7 days 



HISTORY OF PRESENT ILLNESS

*Patient was apparently asymptomatic  10 days back  then he developed shortness of breath which was of grade 3 intially and gradually progressed to present stage of garde 4 
*Palpitations which was not associated with excessive sweating and chest pain 

*No H/O fever , vomit,loose stools.



No history of Diabetes mellitus, Hypertension,CVA,CAD,TB, ASTHMA

PERSONAL HISTORY

 * Diet: Mixed
 *Appetite:Normal
 *Bowel and Bladder: Regular
 *Allergies:None
 *Addiction: Alcohol intake since 15 years wich was occasional and was continuosly exposed to smoking when he was in bar 

FAMILY HISTORY

*Irrelevant

GENERAL EXAMINATION

*Patient was conscious, coherent and cooperative
* No pallor,icterus, clubbing, cyanosis,     lymphadenopathy,no pedal edema

VITALS

*Pulse rate :140bpm
*Respiratory Rate : 30 cpm
* Bp: 130/80 mm hg
* Temperature : afebrile

Systemic examination

CVS

INSPECTION:

Shape of the chest and symmetry: Normal
Breast abnormalities: Absent 
Spine deformities: Absent 
Precordial prominence: Absent
Apical impulse:Not visible
Pulsations in AP area: Absent
Sternoclavicilar pulsations:Absent
Left parasternal pulsations:Absent
Epigastric pulsations:Absent
Dilated viens : Absent

PALPATION

Confirmation of Shape and symmetry
Location of apex beat: 6 th intercostal space and 3cm away from the midclavicular line
Parasternal heave : Absent

PERCUSSION

Dullness corresponding to Right Heart border isnormal
Dullness corresponding to left heart border is shifted 2cm laterally

AUSCULTATION

S1,S2 heard 
No murmurs 




                                                                    Parasternal heave




Dullness corresponding to left border of heart





Dullness corresponding to upper border of heart





Auscultation in mitral area




















INVESTIGATIONS


1.  8\6\22 :  
  • serum creatinine : 1.0 mg\dl
  • blood urea : 22mg\dl
  • serum electrolytes 
  • Na+ - 138 mEq\L.   
  • K+ - 3.9
  • Cl- - 100

  • Ph : 7.43
  • PCo2 : 26.8 mmHg
  • PO2 : 76.3 mmHg
  • HCo3: 17.6 mmol\L
  • St. HCo3 : 20.4 mmol\L
  • TCo2 : 35
  • O2 stat : 94.0
HEMOGRAM :
  • hemoglobin : 12.0 gm\dl
  • TLC : 14,000
  • PCV : 37.6
  • MCV : 70.9
  • MCH : 22.4
  • RDW-CV : 16.9
LIVER FUNTION TESTS : 
  • total bilirubin : 2.32
  • direct bilirubin : 0.64
  • SGPT : 58
  • SGOT : 34

2. 9\6\22 :
  • Ph : 7.43
  • PCo2 : 26.8 mmHg
  • PO2 : 76.3 mmHg
  • HCo3: 17.6 mmol\L
  • St. HCo3 : 20.4 mmol\L
  • TCo2 : 35
  • O2 stat : 94.0


3. 10\6\22: 

HEMOGRAM :
  • Hb : 11.3
  • TLC : 17,100
  • platelets : 3.43

SERUM creatinine : 1.1mg\dl

4.   11\6\22:

   HEMOGRAM :

  • hb : 12.8
  • total count : 14,100
  • platelets : 3.93
  • RBC : 6.04 millions\cumm

PROVISIONAL DIAGNOSIS

 * DILATED CARDIOMYOPATHY WITH ATRIAL FIBRILLATION


TREATMENT

  •  inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min
  • inj AUGMENTIN 1.2gm\IV\BD
  • tab AZITHROMYCIN 500mg PO\BD
  • inj HYDRODRT 100mg IV\BD
  • neb with DUOLIN             @ 8th hourly
  •  BUDSCORT   @ 8th hourly
  • inj LASIX 40mg\IV\BD 
  • inj THIAMINE 200mg in 50ml normal saline IV\TID
  • tab CARDARONE 150mg 
  • tab clopitab 75mg RO OD
  • tab ATROVAS 80MG
  • Fluid restriction <1.5L per day
  • Salt restriction <4gm per day
  • Strict temperature chart 4th hourly 


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