PATIENT CAME WITH THE C/O SHORTNESS OF BREATH

Clinical findings and case history:-

C/O SHORTNESS OF BREATH SINCE YESTERDAY 10PM

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 10PM YESTERDAY SUDDENLY SHE HAD SHORTNESS OF BREATH WHICH IS SUDDEN IN ONSET GRADUALLY PROGRESIVE (GRADE 2 NYHA ) NO H/O FEVER, COUGH, COLD, VOMITINGS, DIARRHOEA, BURNING MICTURITION, DECREASE IN URINE OUTPUT SHE HAD SIMILAR COMPLAINTS ON 1/3/24 AND ADMITTED IN GOVERNAMENT HOSPITAL AND TREATED THERE DISCHARGED ON 3/3/24 AND THEN SHE RECOVERED

K/C/O CKD WITH DIABETIC NEPHROPATHY AND ADMITTED IN OUR HOSPITAL WITH COMPLAINTS OF VOMITINGS AND EPIGASTRIC PAIN ON 16/9/23 AND DISCHARGED ON 19/9/24

PAST HISTORY:-

K/C/O DM SINCE 10YRS ON TAB GLIMI M1 PO/OD NOT USING ANY MEDICATION SINCE NOV 2023

NO H/O DM, TB, ASTHMA. HTN, EPILEPSY

GENERAL EXAMINATION:-


PT IS C/C/C

TEMP - 98.6F

PR - 130BPM

RR - 30CPM

BP - 130/80MMHG

SPO2 - 86% @ RA

GRBS - 464MG %

SYSTEMIC EXAMINATION

CVS - S1, S2 +, NO MURMURS

CNS - NFND

RS - B/L DIFFUSE FINE CREPTS PRESENT

P/A - SOFT NONTENDER

PULMO REFERAL WAS DONE I/V/O ? PULMONARY TB

AND ADVISED TO REVIEW WITH REPORTS

COURSE IN THE HOSPITAL

50 YR OLD FEMALE FARMER BY OCCUPATION K/C/O DM 2 SINCE 10 YRS K/C/O CKD WITH DIABETIC NEPHROPATHY SINCE 6 MONTHS WHO IS ON IRREGULAR MEDICATION CAME WITH C/O SOB AND ON ADMISSION VITALS WERE

TEMP - 98.6F

PR - 130BPM

RR - 30CPM

BP - 130/80MMHG

SPO2 - 86% @ RA

GRBS - 464MG %

6UNITS OF IV INSULIN WAS GIVEN AND NECCESSARY INVESTIGATIONS WERE DONE HRCT SHOWED -

-BILATERAL CENTRAL / PERIHILAR AIR SPACE OPACITIES FEATURES SUGGESTIVE OF PULMONARY EDEMA

SEGMENTAL ATELECTASIS IN B/L LUNG LOWER LOBES

B/L MODERATE PLEURAL EFFUSION

MULTIPLE CYSTS IN BOTH KIDNEYS

AND TROPONIN I 130.3PG/ML AND DIAGNOSED TO BE

CARDIOGENIC PULMONARY EDEMA SECONDARY TO CAD


HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF 40%)

K/C/O CKD SINCE 1 YR

K/C/O DM 2 SINCE 10 YEARS AND STARTED ON ANTIBIOTICS, ECOSPIRIN, INJ HAI ACCORDING TO GRBS, INJ LASIX AND NEB WITH IPRAVENT 6TH HOURLY , BUDECORT 8TH HOURLY PULMONOLOGY REFERRAL WAS DONE AND ADVISED CONTINUE SAME TREATMENT AND PATIENT IMPROVED SYMPTOMATICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

PROVISIONAL DIAGNOSIS:-

CARDIOGENIC PULMONARY EDEMA SECONDARY TO CAD

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF 40%)

K/C/O CKD SINCE 1 YR

K/C/O DM 2 SINCE 10 YEARs


Investigation:-

ABG 10-03-2024 09:10:AM:-

PH 7.351

PCO2 20.0PO2 116

HCO3 10.8St.HCO3 14.1

BEB -13.2

BEecf - 13.8T

CO2 22.8

O2 Sat 94.6

O2 Count 13.0

BLOOD UREA 10-03-2024 -108 mg/dl 

SERUM CREATININE 10-03-2024 -3.4 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 10-03-2024 :-

SODIUM 141 mmol/L 

POTASSIUM 5.6 mmol/L 

CHLORIDE 106 mmol/L 

HBsAg-RAPID 10-03-2024 Negative

Anti HCV Antibodies - RAPID 10-03-2024 -Non Reactive

FBS # 477mg/dLPOST LUNCH BLOOD SUGAR 10-03-2024 321 mg/dl

BLOOD GROUP RH TYPING : B POSITIVE (+VE)

HEMOGRAM 10-03-2024

HAEMOGLOBIN # 9.6 gm/dl

TOTAL COUNT # 14,800 cells/cumm

RBC COUNT 3.85 millions/cumm

PLATELET COUNT 4.70 lakhs/cu.mm

IMPRESSION :Normocytic normochromic anemia with neutrophilic leukocytosis and thrombocytosis .

SERUM IRON 54ug/dl

URINE FOR KETONE BODIES: NEGATIVE(-VE)

LIVER FUNCTION TEST (LFT) 10-03-2024 

Total Bilurubin 1.14 mg/dl 

Direct Bilurubin 0.17 mg/dl 

SGOT(AST) 12 IU/L 

SGPT(ALT) 11 IU/L 

ALKALINE PHOSPHATASE 245 IU/L

TOTAL PROTEINS 7.9 gm/dl 

ALBUMIN 3.55 gm/dl 

A/G RATIO 0.82

COMPLETE URINE EXAMINATION (CUE) 10-03- 2024

 COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN ++++

SUGAR +

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS plenty

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

SERUM ELECTROLYTES (Na, K, C l) 10-03-2024 :-

SODIUM 137 mmol/L

 POTASSIUM 4.8 mmol/L 

CHLORIDE 99 mmol/L 

BLOOD UREA 11-03-2024 05:19:AM 125 mg/dl

HEMOGRAM:-

HAEMOGLOBIN # 8.0gm/dl

TOTAL COUNT # 15,500 cells/cumm

RBC COUNT # 3.28 millions/cumm

PLATELET COUNT 4.0 lakhs/cu.mm

IMPRESSION : Normocytic normochromic Anemia with Leukocytosis.

SERUM CREATININE 11-03-2024 3.4 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) 11-03-2024 :-

SODIUM 141 mmol/L

 POTASSIUM 4.5 mmol/L 

CHLORIDE 105 mmol/L


TROPONIN-I # 130.3 pg/ml

T3, T4, TSH 11-03-2024 :-

T3 0.51 ng/ml 

T4 13.42 micro g/dl 

TSH 0.96 micro Iu/ml 

lBLOOD UREA 11- 03-2024 120 mg/dl l

SERUM CREATININE 11-03-2024 3.4 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) 11-03-2024 :-

SODIUM 137 mmol/L 

POTASSIUM 3.8 mmol/L 

CHLORIDE 102 mmol/L

HAEMOGLOBIN# 8.1gm/dl

TOTAL COUNT# 12,600cells/cumm

RBC COUNT # 3.16millions/cumm

PLATELET COUNT 3.72lakhs/cu.mm

IMPRESSION Normocytic normochromic Anemia with Leukocytosis.

24H URINE PROTEIN/CREATININE RATIO

24 HOURS URINE PROTEIN 480 mg/day.

24 HOURS URINE CREATININE 0.9g/dayRATIO 0.53URINE VOLUME 2,000ml

HEMOGRAM 12-03-2024

HAEMOGLOBIN# 8.1gm/dl

TOTAL COUNT# 12,600cells/cumm

RBC COUNT# 3.16millions/cumm

PLATELET COUNT3.72lakhs/cu.mm

IMPRESSIONNormocytic normochromic Anemiawith Leukocytosis.

BLOOD UREA 12-03-2024 111 mg/dl 

SERUM CREATININE 12-03-2024 3.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 12-03-2024 :-

SODIUM 140 mmol/L POTASSIUM 3.9 mmol/L

TROPONIN-I # 130.3 pg/ml

T3, T4, TSH 11-03-2024 :-

T3 0.51 ng/ml 

T4 13.42 micro g/dl TSH 0.96 micro Iu/ml lBLOOD UREA 11- 03-2024 120 mg/dl l

SERUM CREATININE 11-03-2024 :-3.4 mg/dl 

SERUM ELECTROLYTES (Na, K, C l) 11-03-2024:-

 SODIUM 137 mmol/L 

POTASSIUM 3.8 mmol/L 

CHLORIDE 102 mmol/L

HAEMOGLOBIN# 8.1gm/dl

TOTAL COUNT# 12,600cells/cumm

RBC COUNT # 3.16millions/cumm

PLATELET COUNT 3.72lakhs/cu.mm

IMPRESSION Normocytic normochromic Anemia with Leukocytosis.

24H URINE PROTEIN/CREATININE RATIO

24 HOURS URINE PROTEIN 480 mg/day.

24 HOURS URINE CREATININE 0.9g/dayRATIO 0.53URINE VOLUME 2,000ml

HEMOGRAM 12-03-2024

HAEMOGLOBIN# 8.1gm/dl

TOTAL COUNT# 12,600cells/cumm

RBC COUNT# 3.16millions/cumm

PLATELET COUNT3.72lakhs/cu.mm

IMPRESSIONNormocytic normochromic Anemiawith Leukocytosis.

BLOOD UREA 12-03-2024 -111 mg/dl 

SERUM CREATININE 12-03-2024 -3.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 12-03-2024:-

 SODIUM 140 mmol/L 

POTASSIUM 3.9 mmol/L 

CHLORIDE 98 mmol/L


USG ABDOMEN:-

IMPRESSION - B/L RENAL CORTICAL CYST

B/L GRADE 3 RPD CHANGES IN KIDNEYS

B/L MILD TO MODERATE PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATORY CHANGES


2DECHO:-

RWMA +

MILD AR +, MODERATE MR + WITH PAH

MODERATE LV DYSFUNCTION PRESENT

GRADE 1 DIASTOLIC DYSFUNCTION

MINIMAL PE +, PLEURAL EFFUSION PRESENT

BLOOD C/S REPORT : NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION.

URINE C/S REPORT: NO BACTERIAL GROWTH.

HRCT CHEST

-BILATERAL CENTRAL / PERIHILAR AIR SPACE OPACITIES FEATURES SUGGESTIVE OF PULMONARY EDEMA

SEGMENTAL ATELECTASIS IN B/L LUNG LOWER LOBES

B/L MODERATE PLEURAL EFFUSION

MULTIPLE CYSTS IN BOTH KIDNEYS

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2G/DAY

TAB AUGMENTIN 625MG PO/BD

TAB CLINDAMYCIN 600MG PO/BD

INJ HAI SC /TID 5 UNITS

TAB LASIX 40MG PO/BD

NEB WITH IPRAVENT 6TH HOURLY , BUDECORT 8TH HOURLY

TAB NODOSIS 500MG PO/BD

TAB METFORMIN + VILDAGLIPTIN 500/50 PO/BD

TAB OROFER XT PO/OD

TAB SHELCAL 500MG PO/OD

TAB MET-XL 12.5MG PO/OD

TAB ECOSPIRIN GOLD PO/HS


Comments

Post a Comment

Popular posts from this blog

My experience with general cellular pathology in a case based blended learning ecosystem’s CBBLE

  WARM REGARDS, I'm shivani tunia, a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you. Together, let's delve into the captivating world of patient care, where every interaction holds the potential for learning, growth, and making a positive impact on the lives of those we serve. Thank you for joining me on this incredible journey! CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONL...
Read more

70 YEAR OLD FEMALE WITH FEVER AND LEFT SIDED PAIN

Image
 T.shivani   MBBS 9th semester Roll no:06 This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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 diagnosis . Following is the view of my case.. 70 yr old female with fever and left sided chest pain . January 11, 2022 A 70 year old female came to casuality on 05-01-2022 with...
Read more

A 55 YEAR OLD PATIENT WITH FEVER CHEST PAIN AND LOSS OF APPETITE

Image
January 01, 2023   A 55 years old patient presented with fever, chest pain and loss of appetite 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 inputs on the comment box"  - 55  year old male,  -farmer by occupation,   -came to Medicine OPD with complaints of :-  —>  Chief Complaints: -( Fever since 13 days , chest pain since 10 days, and loss of appetite since 10 days ) -History of present illness:- —>Patient was apparently asymptomatic 8 months ago then he developed fever , cough, shortness of breath on exertion fever is of h...
Read more