Friday, May 28, 2021

A 40 YEAR OLD WITH SHORTNESS OF BREATH

 

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

 






 HR-CT














Treatment given (day1)

  1. Propped up posture 
  2. O2 inhalation (To maintain saturation’s >/= 94% ) 
  3. IVF 1.NS 1.RL @ 75ml/hr 
  4. Inj Augmentin 1.2gm IV TID 
  5. INJ PAN 40mg IV od 
  6. Inj clexane 40mg s/c OD
  7. Candid mouth paint 
  8. GRBS CHARTING 6th hourly
  9. Inj human actrapid insulin s/c 

 8am-2pm-8pm  


Treatment given (day2)

  1. Propped up posture 
  2. O2 inhalation (To maintain saturation’s >/= 94% ) 
  3. IVF 1.NS 1.RL @ 75ml/hr 
  4. Inj Augmentin 1.2gm IV TID 
  5. INJ PAN 40mg IV od 
  6. Inj clexane 40mg s/c OD 
  7. Tab Bactrim DS (800/160mg)PO OD
  8. TAB FLUCONAZOLE 150mg PO OD
  9. 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 
  10. Candid mouth paint 
  11. GRBS CHARTING 6th hourly
  12. Inj human actrapid insulin s/c 

 8am-2pm-8pm






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