70 Y / M CAME WITH C/O COUGH NON PRODUCTIVE, SOB SINCE 5 DAYS

 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. 

C/O COUGH NON PRODUCTIVE, SOB SINCE 5 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOPMATIC 5 DAYS GO THEN DEVELOPED COUGH INSIDIOUS IN ONSET, NON PRODUCTIVE, MORE AT NIGHT TIME AGGREVATED IN SUPINE POSITION

C/O SOB GRADE III MMRC INSIDIOUS IN ONSET

H/O CHEST PAIN, ORTHOPNEA , PND

H/O COLD , LOSS OF APPETITE, LOSS OF WEIGHT

NO H/O PALPITATIONS, PEDAL EDEMA

NO H/O FEVER , ABDOMINAL DISTENSION, FACIAL PUFFINESS

NO H/O SWEATING

PAST HISTORY:

K/C/O ? CAD SINCE 2 YEARS NOT USING ANY MEDICATION SINCE 2 MONTHS , 

NOT K/C/O HTN ,DM, EPILEPSY, ASTHMA, THYROID DISORDER , CVA

 

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:130/90 MM HG

PR:120 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

 

COURSE IN THE HOSPITAL

PT WAS BROUGHT WITH  COMPLAINTS OF DRY COUGH AND SHORTNESS OF BREATH ,VITALS AT ADMISSION WERE STABLE ON DAY 2 OF ADMISSION PT DEVELOPED PALPITATIONS ECG WAS DONE IT SHOWED PSVT AND VITALS WERE STABLE SO GIVEN  12 MG ADENOSINE ARRYTHMIAS SUBSIDED .THEN AGAIN DEVELOPED PSVT AND VITALS WERE UNSTABLE WITH SBP 60MMHG FOR WHICH 50J SYNCHRONISED CARDIOVERSION DONE RYTHM NOT REVERTED THEN 100J SYNCHRONISED CARDIOVERSION AND THEN RYTHM REVERTED LATER PATIENT WAS STARTED ON TAB DIGOXIN 0.5 MG STAT F/B 0.25 MG OD

 INVESTIGATIONS:

HBsAg-RAPID 10-01-2024 04:11:PM negative

Anti HCV Antibodies - RAPID 10-01-2024 04:11:PM Non Reactive

RFT 10-01-2024

UREA 87 mg/dl 50-17 mg/dl

CREATININE 2.3 mg/dl 1.3-0.8 mg/dl

URIC ACID 6.7 mg/dl 7.2-3.5 mg/dl

CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.6 mg/dl 4.5-2.5 mg/dl

SODIUM 134 mEq/L 145-136 mEq/L

POTASSIUM 3.9 mEq/L 5.1-3.5 mEq/L

CHLORIDE 101 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 10-01-2024

Total Bilurubin 1.59 mg/dl 1-0 mg/dl

Direct Bilurubin 0.45 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 58 IU/L 35-0 IU/L

SGPT(ALT) 62 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 141 IU/L 119-56 IU/L

TOTAL PROTEINS 6.1 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.85 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.10

COMPLETE URINE EXAMINATION (CUE) 10-01-2024

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN ++

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 3-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

ABG 11-01-2024

PH 7.51

PCO2 22.4

PO2 58.2

HCO3 17.9

St.HCO3 22.3

BEB -2.3

BEecf -4.7

TCO2 32.5

O2 Sat 92.8

O2 Count 23.0

BLOOD UREA 12-01-2024 01:17:AM 56 mg/dl 50-17 mg/dl

SERUM CREATININE 12-01-2024 2.0 mg/dl 1.3-0.8 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024

SODIUM 135 mEq/L 145-136 mEq/L

POTASSIUM 3.5 mEq/L 5.1-3.5 mEq/L

CHLORIDE 101 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.17 mmol/L mmol/L

BLOOD UREA 13-01-2024 56 mg/dl 50-17 mg/dl

SERUM CREATININE 13-01-2024 1.5 mg/dl 1.3-0.8 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 13-01-2024

SODIUM 136 mEq/L 145-136 mEq/L

POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L

CHLORIDE 102 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.10 mmol/L mmol/L

RFT 13-01-2024 11:36:PM

UREA 87 mg/dl 50-17 mg/dl

CREATININE 1.7 mg/dl 1.3-0.8 mg/dl

URIC ACID 8.0 mg/dl 7.2-3.5 mg/dl

CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.4 mg/dl 4.5-2.5 mg/dl

SODIUM 138 mEq/L 145-136 mEq/L

POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L

CHLORIDE 102 mEq/L 98-107 mEq/L

COMPLETE URINE EXAMINATION (CUE) 13-01-2024 11:36:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

RFT 15-01-2024 12:49:AM

UREA 75 mg/dl 50-17 mg/dl

CREATININE 1.7 mg/dl 1.3-0.8 mg/dl

URIC ACID 6.9 mg/dl 7.2-3.5 mg/dl

CALCIUM 9.3 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.3 mg/dl 4.5-2.5 mg/dl

SODIUM 138 mEq/L 145-136 mEq/L

POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L

CHLORIDE 103 mEq/L 98-107 mEq/L

HEMOGRAM 9/1/2024

HB 12.1

TLC - 13000

PLATELET - 2.1 LAKHS

HEMOGRAM 11/1/2024


HB 14.3

TLC - 9300

PLATELET - 2.7 LAKHS

HEMOGRAM 13/1/2024


HB 11.8

TLC - 7400

PLATELET - 2.1 LAKHS

 

HEMOGRAM 15/1/2024


HB 14.0

TLC - 7100

PLATELET - 2.89 LAKHS

HEMOGRAM 16/1/2024

HB 13.6

TLC - 9500

PLATELET - 3.05 LAKHS

24 HOURS URINE PROTEIN

132.4 mg/day.

24 HOURS URINE CREATININE

1.84 g/day
1-3 gm /day

RATIO 7.19


URINE VOLUME 600 ml

LIPID PROFILE 14/1/24

Total CholesteroL 199 mg/dl

Triglycerides # 162 mg/dl

HDL Cholesterol # 34.9 mg/dl

LDL Cholesterol # 102 mg/dl.

VLDL 32.4 mg/dl

11/1/24 TROPONIN I 138.2 PG/ML

12/1/24

BLOOD UREA # 56 mg/dl
CREATININE # 2.0 mg/dl
CALCIUM IONIZED 1.17
SODIUM 135 mEq/L
POTASSIUM 3.5 mEq/L
CHLORIDE  101 mEq/L

13/1/24

UREA #56 MG/Dl

CREATININE # 1.5 mg/dl

CALCIUM 1.0

PHOSPHOROUS# 2.4 mg/dl

SODIUM 136 mEq/L
POTASSIUM 3.7 mEq/L

CHLORIDE  102 mEq/L

 

14/1/24

 

UREA # 87 mg/dl

CREATININE # 1.7 mg/dl


URIC ACID  # 8.0 mg/dl


CALCIUM 10.0 mg/dl

PHOSPHOROUS# 2.4 mg/dl

SODIUM 138 mEq/L


POTASSIUM 3.6 mEq/L

CHLORIDE  102 mEq/L

 

15/1/24

UREA # 75 mg/dl

CREATININE # 1.7mg/dl


URIC ACID 6.9 MG/DL

CALCIUM 9.3 mg/dl

PHOSPHOROUS# 3.3 mg/dl

SODIUM 138 mEq/L


POTASSIUM 3.7 mEq/L

CHLORIDE  103 mEq/L

16/1/24

UREA 20 mg/dl

CREATININE # 1.6 mg/dl


URIC ACID
# 8.7 mg/dl


CALCIUM 10.0 mg/dl

PHOSPHOROUS# 2.7 mg/dl

SODIUM 137 mEq/L


POTASSIUM 3.3 mEq/L

CHLORIDE  99 mEq/L

 

USG ABDOMEN ON 11/1/24

IMPRESSION: GRADE II RPD CHANGES IN B/L KIDNEYS, B/L RENAL CORTICAL CYSTS.

 

2D ECHO :

EF:35 %

ECCENTRIC MR + MODERATE MR+ MILD TR+ , MILD AR + , RWMA + , RCA HYPOKINETIC, LAD HYPOKINESIA, MODDERATE TO SEVERE LV DYSFUNCTION , DIASTOLIC DYSFUNCTION + , NO PE.

DX: HEART FAILURE WITH REDUCED EJECTION FRACTION 35%

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

COPD

TREATMENT:

FLUID RESTRICTION < 1. 5 L /DAY

SALT RESTRICTION <2 G /DAY

INTERMITTENT CPAP

INJ AUGMENTIN 1.2 GM IV/BD

TAB AZITHROMYCIN 500 MG PO/OD

INJ CLEXANE  40 MG SC/BD

INJ. HYDROCORT 100 MG IV TID 

INJ LASIX 20 MG IV / TID

T.ALDACTONE 25 MG OD X-1-X

T.DIGOXIN  0.25 MG PO / OD 1-X-X

T.PULMOCLEAR BD 1-X-1

T.MONTEC LC OD / H/S X-X-1

SYP. LUPITUS 10 ML TID

NEB WITH IPRAVENT 6TH HOURLY

BUDECORT 12TH HOURLY

Comments

Post a Comment

Popular posts from this blog

1801006143 - long

Image
    1801006143 - long case 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 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. A 57 year old male, resident of Nakrekal, mason by occupation came to hospital with chiefs complaints of   shortness of breath since 1 week Decreased urine output since ...
Read more

MY INTERNSHIP JOURNEY IN GENERAL MEDICINE.

Image
I am Ravula Sankeerthana, Intern posted in the General Medicine Department from 1/12/23 until 31/1/24. 1.SELF REFLECTIVE WRITING ON MY MEDICAL STUDENT CAREER  I  started seeing cases from my 3rd semester posting which was my very first experience with the clinics, It was very overwhelming pretty much the entire year. I  learned lot from my professor , some times I find myself suprised by hearing about cases and the way they approach the understanding of each case and linking the history about the case to diagnose the case and to explain how to understand a case and to diagnose a case. My 1st case I saw in detail  was Heart failure in gm posting so I studied the case in detail  during my posting along with understanding where my pgs , faculty helped to take history step by step. Here is the link of the case http://ravulasankeerthanarollno134.blogspot.com/2022/10/a-75-old-female-with-chief-complaints.html During my general medicine posting as an intern,it started ...
Read more

77 Y /M CAME WITH C/O DECREASED URINE OUTPUT AND SOB SINCE 4 DAYS ; C/O PEDAL EDEMA SINCE 1 DAY

 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.  C...
Read more