PATIENT CAME WITH THE COMPLAINTS OF SHORTNESS OF BREATH SINCE 15 DAYS

 Case History and Clinical Findings

PATIENT CAME WITH THE COMPLAINTS OF SHORTNESS OF BREATH SINCE 15 DAYS

B/L PEDAL EDEMA AND FACIAL PUFFINESS SINCE 3 DAYS

BURNING MICTURITION AND DECREASED URINE OUTPUT SINCE 2 DAYS

HOPI:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS AGO THEN HE DEVELOPED SHORTNESS OF BREATH AND VISITED A LOCAL DOCTOR AND TOOK TREATMENT THEN IT SUBSIDED

NOW PATIENT PRESENTED WITH SHORTNESS OF BREATH SINCE 15 DAYS,INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE FROM GRADE 1 TO GRADE 3,ORTHOPNEA PRESENT, NO PND

NO H/O CHEST PAIN, PALPITAIONS , EXCESSIVE SWEATING,GIDDINESS,VOMITING

B/L PEDAL EDEMA PRESENT ,PITTING TYPE ,EXTENDING UPTO THE KNEE JOINT AND FACIAL PUFFINESS PRESENT SINCE 3 DAYS

BURNING MICTURITION AND DECREASED URINE OUTPUT SINCE 2 DAYS

NO H/O FEVER,COUGH,COLD ,VOMITINGS,LOOSE MOTIONS

PAST HISTORY

K/C/O TYPE 2 DM SINCE 6 YEARSAND ON TAB METFORMIN 500MG PO/OD

K/C/O HTN SINCE 8 YEARS AND ON TAB METOPROLOL 0.25MG PO/OD

H/O CVA 8 YEARS AGO?TIA TOOK MEDICATION FOR 2 MONTHS AND THEN STOPPED[TAB HYDRALAZINE 37.5MG , TAB ROSUVASTATIN 10MG, AND TAB CLOPIDOGREL,DYTOR PLUS 5 MG ]

NOT A K/C/O TB,ASTHMA,EPILEPSY,CAD,THYROID DISORDERS

PERSONAL HISTORY

K/C/O ALCOHOLIC STOPPED SINCE 2 YEARS

STOPPED SMOKING SINCE 6 YEARS

FAMILY HISTORY NOT SIGNIFICANT

ON GENERAL PHYSICAL EXAMINATION

PT IS CONSCIOUS ,COHERENT, NON COOPERATIVE

TEMP : 96.8 F

PR : 70 BPM

BP : 130/90 MM HG

RR : 20/MIN

SPO2 87% AT ROOM AIR

100% 4LIT OF O2

GRBS : 186 MG /DL

PALLOR PRESENT

NO ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY.

BILATERAL PITTING TYPE EXTENDING UP TO KNEE

CVS : S1 S2 HEARD NO MURMURS

RS : BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+

DYSPNEA PRESENT

WHEEZE PRESENT B/L

CREPS PRESENT B/L

P/A : SOFT ,NON TENDER

BOWEL SOUNDS HEARD

CNS-

MOTOR SYSTEM-

NORMAL TONE IN BOTH UPPER AND LOWER LIMBS

POWER 5/5 IN ALL LIMBS

REFLEXES B / T / S / K / A / P

RT 2+ / 1+ / 1+ / 2 + / 1+ / F

LT 2+ / 1 + / 1+ / 2 + / 1+ / F

SENSORY EXAMINATION NORMAL

NO CEREBELLAR SIGNS

NORMAL GAIT AND NO MENINGEAL SIGNS

GCS SCORE E4V5M6

COURSE IN THE HOSPITAL

PATIENT CAME WITH THE COMPLAINTS OF SHORTNESS OF BREATH SINCE 15 DAYS

B/L PEDAL EDEMA AND FACIAL PUFFINESS SINCE 3 DAYS

BURNING MICTURITION AND DECREASED URINE OUTPUT SINCE 2 DAYS

INJ LASIX 40MG IV STAT

TAB ECOSPRINE AV 78/10MG OD/HS

TAB METOPROLOL 25MG/OD

INJ HAI S/C 7 POINT PROFILE

OXYGEN SUPPLEMENTATION TO MAINTAIN SPO2 GREATER THAN 94%

INTERMITTENT CPAP

USG ABDOMEN AND PELVIS WAS DONE

IMPRESSION

B/L PLEURAL EFFUSION MILD TO MODERATE PRESENT

GRADE 1 FATTY LIVER

RAISED ECHOGENCITY OF B/L LIDNEYS

2D ECHO WAS DONE:-

IMPRESSION

EF 62%

MODERATE MR,AR,TR PRESENT WITH PAH

NO RWMA,NO MS ?MILD AS PRESENT SCLEROTIC

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION PRESENT

NO PE

DAY 1

I UNIT PRBC TRANSFUSION DONE

INJ LASIX 40MG IV BD

INJ HAI S/C 7 POINT PROFILE

TAB ECOSPRINE AV 78/10MG OD/HS

TAB METOPROLOL 25MG/OD

NEBULIZATION WITH IPRAVENT 12TH HOURLY

BUDECORT 12 HOURLY

OXYGEN SUPPLEMENTATION TO MAINTAIN SPO2 GREATER THAN 94%

INTERMITTENT CPAP

PATIENT AND PATIENT ATTENDERS HAVE BEEN ADVISED FOR SERUM IRON PROFILE AND BONE MARROW BIOPSY BUT THEY ARE NOT WILLING FOR THE INVESTIGATIONS

DAY 2

C/O SOB DECREASED COMPARED TO THE PREVIOUS DAY

1 UNIT PRBC TANSFUSION DONE

SAME TREATMENT CONTINED WITH ADDITION OF

TAB CLINIDIPINE 10MG/BD

TAB PANTOP 40MG PO/OD

SYP CREMAFFIN 20ML PO/HS

DAY 3

C/O SOB DECREASED COMPARED TO THE PREVIOUS DAY

SAME TREATMENT CONTINED

BLOOD CULTURE AND SENSITIVITY SHOWED NO GROWTH AFTER 24 HOURS OF ANEROBIC INCUBATION

URINE CULTURE AND SENSITIVITY SHOWED E COLI >10 TO THE POWER OF 5 CFU/ML OF URINE ISOLATED

DAY 4

C/O SOB DECREASED COMPARED TO THE PREVIOUS DAY

SAME TREATMENT CONTINED WITH ADDITION OF AGUMENTIN 625MG PO/TID

SYP POTKLOR 10ML PO/TID

DAY 5

C/O SOB DECREASED

SAME TREATMENT CONTINED

ONE UNIT OF PRBC TRANSFUSION DONE

DAY 6

SAME TREATMENT CONTINED WITH ADDITION OF TAB OROFER XT PO BD

AND PULMONOLOGY REVIEW DONE AND

ADVISED SYP ASCORIL LS2 TSBP PO TID

SPUTUM AFB,C/S,GS,FS AND SPUTUM CBNAAT

NO COMPLAINTS AND PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE STATE


Provisional Diagnosis:-

ANEMIA[MICROCYTIC HYPOCHROMIC] SECONDARY TO ?IDA?MDS.

CARDIOGENIC PULMONARY EDEMA[RESOLVED] SECONDARY TO HEART FAILURE WITH PRESERVED EJECTION FRACTION-62% WITH

RENAL AKI ON CKD


Investigation:-

USG ABDOMEN AND PELVIS WAS DONE

IMPRESSION

B/L PLEURAL EFFUSION MILD TO MODERATE PRESENT

GRADE 1 FATTY LIVER

RAISED ECHOGENCITY OF B/L LIDNEYS

2D ECHO WAS DONE

IMPRESSION

EF 62%

MODERATE MR,AR,TR PRESENT WITH PAH

NO RWMA,NO MS ?MILD AS PRESENT SCLEROTIC

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION PRESENT

NO PE

BLOOD CULTURE AND SENSITIVITY SHOWED NO GROWTH AFTER 24 HOURS OF ANEROBIC INCUBATION

URINE CULTURE AND SENSITIVITY SHOWED E COLI >10 TO THE POWER OF 5 CFU/ML OF URINE ISOLATED


Treatment Given:-

INJ LASIX 40MG IV BD

INJ HAI S/C 7 PONT PROFILE

TAB ECOSPRINE AV 78/10MG OD/HS

TAB METOPROLOL 25MG/OD

TAB CLINIDIPINE 10MG/BD

TAB PANTOP 40MG PO/OD

AGUMENTIN 625MG PO/TID

SYP POTKLOR 10ML PO/TID

SYP CREMAFFIN 20ML PO/HS

NEBULIZATION WITH IPRAVENT 12TH HOURLY

BUDECORT 12 HOURLY

OXYGEN SUPPLEMENTATION TO MAINTAIN SPO2 GREATER THAN 94%

INTERMITTENT CPAP

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