A 53 year old female with SOB

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MARCH 8, 2022

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments 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 competency in reading and comprehending clinical data including history, clinical finding, investigation.

K.TEJA SREE , ROLL NO:54 ,  9th SEM

CASE

A 53yr old female ,who is a homemaker came to the casualty with complaints of
SOB since 1day.


HOPI: she was apparently asymptomatic 4days back. 
Then while walking she slipped and fallen on ground on 4th march and injured her left knee and had pain and swelling of the left knee for which she came to the hospital.
On xray it showed fracture of distal femur and proximal tibia of left leg 


Since 2days (6th march) she had shortness of breath , on and off which is if of grade 1? Which is insidious in onset 
No diurnal or postural variation
No complaints of cough, fever, chest tightness, palpitations 

PAST HISTORY:

She is a known case of hypertension since 2yrs and on olmesartan, 

diabetes since 2yrs- on glimiperide,

hypothyoid since3 yrs -on thyronom, 

She has asthma since 10years and inhaler 

not a known case of CAD, TB,epilepsy  

H/o spine surgery 15years back for spinal injury due to fall


PERSONAL HISTORY:

Appetite : Normal

Diet : mixed

Bladder & bowel : regular

Sleep :adequate

no addictions

FAMILY HISTORY:

insignificant

GENERAL EXAMINATION

Patient is conscious, cooperative and coherent 
Well oriented to time, place and person
She is moderately built and well nourished.

She was examined after taking consent

  • Pallor  : absent
  • Icterus  : absent
  • Cyanosis : absent
  • Clubbing  : absent
  • Lymphadenopathy  : absent
  • Edema  :  absent

Vitals

  • Pulse rate  : 75bpm
  • Bp  : 130/80mmhg
  • Temperature : afebrile
  • Respiratory rate  : 17cpm
  • GRBS : 104mg%
   EXAMINATION OF LEG:



  • On examination 
     Left leg external rotated
     Skin over swelling-pigmented
     Tenderness over left knee joint 
     Diffuse left knee joint swelling
     Crepitations present
     Distal pulses felt
     No abnormal mobility


        SYSTEMIC EXAMINATION

  • RESPIRATORY SYSTEM

            -position of trachea: central

            - bilateral air entry present

             -normal vesicular breath sounds                                             

  • CARDIOVASCULAR SYSTEM   : S1, S2 heard and no thrills and no murmurs

  • PER ABDOMEN : soft non tender non distended.
  • CNS: higher motor functions are intact.

INVESTIGATIONS:

On 4/3/2022: CT LEFT KNEE JOINT



On 5/3/2022




2D echo


On 7/3/2022


ECG-

On 8/3/2022


On 9/3/2022


Xrays
On 4/3/2022

On 5/3/2022- chest xray



On 8/3/2022 -spine xray



PROVISIONAL DIAGNOSIS:

SOB and closed distal femur and proximal tibia fracture 

TREATMENT 
7/3/2022: 
  O2 2-4liters to maintain spo2 >94%
  Budecort- 12th hourly
  Monitor vitals 
  Temperature charting
  
8/3/2022
  Budecort 8th hourly
  Inj. LMWH s.c
  Inj. Hydrocort 100mg IV stat
  O2 inhaler to maintain >_ 95%
  Monitor vitals
  Monitor BP
  T. Silenafil 25mg BD

  












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