Tondapu Sreelekha, 8th semester
Roll no. – 135
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 centred
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 and treatment plan.
Following is the view of my case: (history as per date of admission)
CASE
A40 year-old female came to the causality
with chief complaints of shortness of breath since 1 week
HISTORY OF PRESENTING ILLNESS
· The patient was apparently asymptomatic
7 days ago, when she developed shortness of breath 1 week back (grade 2 NYHA
classification). It was insidious in onset and gradually progressive in nature
and attained a present state (grade 4 NYHA classification).
·
It was
associated with occasional dry cough, generalized weakness and occasional
palpitations.
·
She has
no complains of fever, sore throat, loss of taste and smell.
PAST HISTORY
- She is a known case of diabetes since years for which she is on regular medication.
- She is not a known case of hypertension, TB, Asthma and epilepsy.
- RAT for COVID-19 was negative
DRUG HISTORY
·
Glimepiride
·
Metformin
For the past 6 years.
PERSONAL HISTORY
· DIET- Mixed
· APPETITE- normal
· SLEEP- Adequate
· BOWELS- Regular
· MICTURATION- Normal
· ADDICTIONS- None
· ALLERGIES- None
FAMILY HISTORY
· There is no
significant family history.
·
GENERAL EXAMINATION
The patient was conscious, coherent and cooperative. She is well
oriented to time, place and person.
She is moderately built and is moderately nourished.
· No pallor
· No icterus
· No cyanosis
· No clubbing
· No generalized
lymphadenopathy
· No pedal oedema
VITALS at the time of admission
· Temperature: Afebrile
· Pulse: 98 beats/mins
· Blood pressure: 100/80
mmHg
· Respiratory rate: 32
cycles/min
· SpO2: 58% at room air
SYSEMIC EXAMINATION
CVS
· S1 and S2 heart
sounds heard.
· No murmurs heard.
Respiratory system
· Bilateral air entry +
· Decreased breath sounds on right side
CNS
Intact
Abdomen
· Soft and non-tender.
· Bowel sounds were
heard.
· No organomegaly.
INVESTIGATIONS
LFT
· Total bilirubin: 0.90
mg/dl
· Direct bilirubin: 0.20
mg/dl
· SGOT: 13 IU/L
· SGPT: 13 IU/ L
· ALP: 299 IU/L
· Total proteins: 7.5
gm/dl
· Albumin: 3.0 gm/dl
· A/G ratio: 0.66
RFT
· Blood urea: 43 mg/dl
· Serum creatinine: 0.6
mg/dl
· Uric acid: 3.6 mg/dl
· Calcium: 9.6 mg/dl
· Phosphorus: 3.8 mg/dl
· Sodium: 134 mEq/L
· Potassium: 4.6 mEq/L
·
Chloride:
96 mEq/L
Haemoglobin: 10.33 gm/dl
PCV: 32.5
MCV: 65.2
MCH: 20.7
MCHC: 31.7
RDW-CV: 16.4
RDW-SD: 40.6
RBC: 4,99,000 cells/cubic meter
Blood picture: microcytic hypochromic blood
smear
TLC: 12,100
· Neutrophils: 84
· Lymphocytes: 10
· Monocytes: 3
· Eosinophils: 3
Platelets: 4,00,000
ABG
X-ray.
ECG
Treatment given (day1)
- Propped up posture
- O2 inhalation (To maintain saturation’s >/= 94% )
- IVF 1.NS 1.RL @ 75ml/hr
- Inj Augmentin 1.2gm IV TID
- INJ PAN 40mg IV od
- Inj clexane 40mg s/c OD
- Candid mouth paint
- GRBS CHARTING 6th hourly
- Inj human actrapid insulin s/c
8am-2pm-8pm
Treatment given (day2)
- Propped up posture
- O2 inhalation (To maintain saturation’s >/= 94% )
- IVF 1.NS 1.RL @ 75ml/hr
- Inj Augmentin 1.2gm IV TID
- INJ PAN 40mg IV od
- Inj clexane 40mg s/c OD
- Tab Bactrim DS (800/160mg)PO OD
- TAB FLUCONAZOLE 150mg PO OD
- TAB PREDNISOLONE 40mg PO OD FOR 5 days f/b Tab prednisolone 40mg OD FOR 5 days followed by Tab prednisolone 20mg OD FOR 21 days
- Candid mouth paint
- GRBS CHARTING 6th hourly
- Inj human actrapid insulin s/c
8am-2pm-8pm
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