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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
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C/O DECREASED URINE OUTPUT AND SOB SINCE 4 DAYS
C/O PEDAL EDEMA SINCE 1 DAY
HOPI:
PATIENT WAS APPARENTLY ALRIGHT 4 DAYS BACK THEN HE HAD DECREASED URINE OUTPUT
NO HESITANCY, NO DRIBBLING OF URINE
C/O SOB GRADE III, ORTHOPNEA +, NO PND
C/O PEDAL EDEMA SINCE 1 DAY WHICVH WAS PITTING TYPE
COUGH SINCE TODAY ASSOCIATED WITH SPUTU, MUCOID, NON FOUL SMELLING,
GENERALISED BODY PAINS+
LOSS OF APPETITE+
3 EPISODES OF VOMITING+ 3 DAYS BACK, FOOD AS CONTENT
PAST HISTORY
NO HISTORY OF DM, HTN,ASTHMA,EPILEPSY,CAD,CVA
PERSONAL HISTORY:
DIET:MIXED
SLEEP:ADEQUATE
BOWEL: PASSED 4 DAYS BACK
BLADDER: URINE OUTPUT DECREASED
ADDICTIONS:ALCOHOL DAILY SINCE 50 YEARS, BEEDI 10 SINCE 50 YEARS
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:101 F
BP:100/60 MM HG
PR:90 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 HO0SPITAL:
PATIENT CAME WITH THE SOB, DECREASED URINE OUTPUT AND PEDAL EDEMA AND DIAGNOSED TO HAVE POLY CYSTIC KIDNEY WITH PERICARDIAL EFFUSION AND PERICARDIOCENTESIS WAS DONE 15 ML PUS WAS COLLECTED AND SENT FOR CULTURES AND CELL COUNT SHOWED 50000 CELLS, NEUTROPHILIC PREDOMINANT.CULTURE REPORTS ARE AWAITED.PATIENT REFERRED TO HIGHER CENTRE FOR INTRA PERICARDIAL FIBRINOLYSIS AND PERICARDIAL DRAINAGE IN VIEW OF PURULENT PERICARDITIS WITH IMPENDING TAMPONADE
INVESTIGATIONS:
| |
| HBsAg-RAPID 10-01-2024 02:36:PM | Negative | |
| | Anti HCV Antibodies - RAPID 10-01-2024 02:36:PM | Non Reactive | |
|
| RFT 10-01-2024 11:22:PM | | UREA | 71 mg/dl | 50-17 mg/dl | | CREATININE | 1.8 mg/dl | 1.3-0.8 mg/dl | | URIC ACID | 6.1 mg/dl | 7.2-3.5 mg/dl | | CALCIUM | 9.8 mg/dl | 10.2-8.6 mg/dl | | PHOSPHOROUS | 3.9 mg/dl | 4.5-2.5 mg/dl | | SODIUM | 135 mEq/L | 145-136 mEq/L | | POTASSIUM | 3.7 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 106 mEq/L | 98-107 mEq/L |
| | LIVER FUNCTION TEST (LFT) 10-01-2024 11:22:PM | | Total Bilurubin | 1.66 mg/dl | 1-0 mg/dl | | Direct Bilurubin | 0.77 mg/dl | 0.2-0.0 mg/dl | | SGOT(AST) | 50 IU/L | 35-0 IU/L | | SGPT(ALT) | 34 IU/L | 45-0 IU/L | | ALKALINE PHOSPHATE | 176 IU/L | 119-56 IU/L | | TOTAL PROTEINS | 5.2 gm/dl | 8.3-6.4 gm/dl | | ALBUMIN | 2.31 gm/dl | 4.6-3.2 gm/dl | | A/G RATIO | 0.80 | |
|
| BLOOD UREA 12-01-2024 12:23:AM | 18 mg/dl | 50-17 mg/dl |
| | SERUM CREATININE 12-01-2024 12:23:AM | 0.9 mg/dl | 1.3-0.8 mg/dl |
|
| SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 12:23:AM | | SODIUM | 137 mEq/L | 145-136 mEq/L | | POTASSIUM | 3.9 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 105 mEq/L | 98-107 mEq/L | | CALCIUM IONIZED | 1.22 mmol/L | mmol/L |
| | BLOOD UREA 13-01-2024 12:30:AM | 39 mg/dl | 50-17 mg/dl |
|
| SERUM CREATININE 13-01-2024 12:30:AM | 1.3 mg/dl | 1.3-0.8 mg/dl |
| | SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 13-01-2024 12:30:AM | | SODIUM | 136 mEq/L | 145-136 mEq/L | | POTASSIUM | 4.5 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 99 mEq/L | 98-107 mEq/L | | CALCIUM IONIZED | 1.13 mmol/L | mmol/L |
|
| RFT 13-01-2024 05:35:PM | | UREA | 57 mg/dl | 50-17 mg/dl | | CREATININE | 1.3 mg/dl | 1.3-0.8 mg/dl | | URIC ACID | 5.3 mg/dl | 7.2-3.5 mg/dl | | CALCIUM | 9.3 mg/dl | 10.2-8.6 mg/dl | | PHOSPHOROUS | 2.5 mg/dl | 4.5-2.5 mg/dl | | SODIUM | 132 mEq/L | 145-136 mEq/L | | POTASSIUM | 3.1 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 98 mEq/L | 98-107 mEq/L |
| | RFT 13-01-2024 11:27:PM | | UREA | 53 mg/dl | 50-17 mg/dl | | CREATININE | 1.3 mg/dl | 1.3-0.8 mg/dl | | URIC ACID | 3.9 mg/dl | 7.2-3.5 mg/dl | | CALCIUM | 10.0 mg/dl | 10.2-8.6 mg/dl | | PHOSPHOROUS | 2.7 mg/dl | 4.5-2.5 mg/dl | | SODIUM | 134 mEq/L | 145-136 mEq/L | | POTASSIUM | 4.1 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 99 mEq/L | 98-107 mEq/L |
|
| RFT 15-01-2024 12:45:AM | | UREA | 67 mg/dl | 50-17 mg/dl | | CREATININE | 1.4 mg/dl | 1.3-0.8 mg/dl | | URIC ACID | 3.6 mg/dl | 7.2-3.5 mg/dl | | CALCIUM | 9.5 mg/dl | 10.2-8.6 mg/dl | | PHOSPHOROUS | 3.6 mg/dl | 4.5-2.5 mg/dl | | SODIUM | 130 mEq/L | 145-136 mEq/L | | POTASSIUM | 4.4 mEq/L | 5.1-3.5 mEq/L | | CHLORIDE | 99 mEq/L | 98-107 mEq/L |
| | LIVER FUNCTION TEST (LFT) 15-01-2024 12:45:AM | | Total Bilurubin | 2.89 mg/dl | 1-0 mg/dl | | Direct Bilurubin | 1.80 mg/dl | 0.2-0.0 mg/dl | | SGOT(AST) | 331 IU/L | 35-0 IU/L | | SGPT(ALT) | 173 IU/L | 45-0 IU/L | | ALKALINE PHOSPHATE | 211 IU/L | 119-56 IU/L | | TOTAL PROTEINS | 5.2 gm/dl | 8.3-6.4 gm/dl | | ALBUMIN | 2.3 gm/dl | 4.6-3.2 gm/dl | | A/G RATIO | 0.81 |
|
HEMOGRAM ON 10/1/24
HAEMOGLOBIN # 12.0 gm/dl
TOTAL COUNT 9,200
NEUTROPHILS 75%
LYMPHOCYTES 20%
EOSINOPHILS # 00%
MONOCYTES 05 %
BASOPHILS 00
RBC COUNT
# 3.64millions/cumm
PLATELET COUNT
1.5
lakhs/cu.mm
HEMOGRAM ON 12/1/24
HAEMOGLOBIN
# 12.0
gm/dl
13.0 - 17.0
Colorimetric
TOTAL COUNT
# 11,000
cells/cumm
4
millions/cumm
PLATELET COUNT
1.5lakhs/cu.mm
HEMOGRAM ON 13/1/24
HAEMOGLOBIN
# 12.1
gm/dl
13.0 - 17.0
Colorimetric
TOTAL COUNT
# 16,600
cells/cumm
RBC COUNT
# 3.6 millions/cumm
PLATELET COUNT
2.8 lakhS/cu.mm
HEMOGRAM DONE ON 15/1/24
HAEMOGLOBIN# 11.8gm/dl
TOTAL COUNT
# 20,100
cells/cumm
RBC COUNT# 3.42 millions/cumm
PLATELET COUNT
4.4 akhs/cu.mm
USG ABDOMEN DONE ON 10/1/24
MILD-MODERATE PERICARDIAL EFFUSION
B/L MILD-MODERATE PLEURAL EFFUSION WITH SEPTATIONS AND LOCULATIONS IN LEFT PLEURAL SPACE WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATIONS
B/L GRADE I RPD CHANGES WITH RENAL CORTICAL CYSTS
PROMINANT HEPATIC VEINS
USG CHEST DONE ON 11/1/24
RIGHT MODERATE PLEURAL EFFUSION WITH UNDERLYING COLLAPSE
LEFT LOCULATED PLEURAL EFFUSION WITH BRONCHOGRAMS
2D ECHO WAS DONE ON 13/1/24
PARADOXICAL IVS
CONCENTRIC LVH +, RVH+
SCLEROTIC AV , IAS INTACT
EF- 65%
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION +
MODERATE TO SEVERE PE+ AND PLEURAL EFFUSION +
IVC SIZE 2.01CMS, DILATED , NON COLLAPSING
D SHAPE LV
HRCT CHEST DONE ON 12/1/24
MODERATE BILATERAL PLEURAL EFFUSION WITH LOCULATED EFFUSION ON LEFT SIDE
INTERLOBAR/ FISSURAL EFFUSION ON LEFT SIDE IN THE MAJOR FISSURE
MODERATE PERICARDIAL EFFUSION
DX:
PURULENT PERICARDITIS[MODERATE TO SEVERE EXUDATIVE EFFUSION]
WITH IMPENDING TAMPONADE
POLYCYSTIC KIDNEY DISEASE WITH AKI
TRATMENT:
INJ PIPTAZ 4.5 GM IV/TID
INJ LASIX 20MG IV/BD
INJ NEOMOL 1 GM IV SOS
TAB MONTAC LC PO H/S
TAB PULMOCLEAR PO BD
TAB PCM 650 MG PO TID
NEB WITH IPRAVENT 8TH HRLY AND BUDECORT 12TH HRLY
SYP LACTULOSE 10ML H/S
PROTEIN POWDER 2 SCOOPS IN ONE GLASS WATER/MILK
2 EGGS/DAY
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