Sannith Reddy -65
68 Year old female
December 14, 2022
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Name: K.SANNITH REDDY
Roll no: 65
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 a diagnosis and treatment plan.
Following is the view of my case :
CASE PRESENTATION:
This is a case of 68 years old female resident of nalgonda has come to the casualty with the chief complaints of
C/o breathlessness since 1 week
Cough since 1 week
Patient was aparently asymptomatic 1 week back then she developed breathlessness which is insidious in onset, MMRC grade 2 not associated with wheeze, palpitations, sweating, seasonal variation +
C/o cough since 1 week, non productive, seasonal variation
No complaints of fever, chest pain, chest tightness, loss of weight, vomiting, diarrhoea
Loss of appetite +
H/o fall in bathroom 10 days back, no head injury
Past history
H/o similar complaints in the past, 5 years back
Hospital admission + and taken treatment
Inhaler usage 2 years back for 1 month and later stopped
Nebulization taken since 1 week (2-3 times)
Known case of HTN since 10 years on medication (Tab. Telma H 40/12.5 OD)
Drug usage- Tab. Montelukast OD since 5 years
Tab. Prednisolone OD since 5 years
Known case of ?hypothyroidism since 4 years not using medication
Not a known case of DM, epilespsy, CAD
No past h/o TB
No h/o any previous surgeries
No known allergies
Personal history:
Diet- Mixed
Appetite- Good
Bowel and bladder movements- Regular
Sleep- Adequate
Family history:
No significant family history
General Physical Examination:
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative
well oriented to time, place and person
well nourished and moderately built
Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent
Vitals
Temperature- 98.8F
Blood pressure- 110/70 mm of Hg
Pulse rate- 98 bpm
Respiratory rate- 21 cpm
SpO2- 96% at 2 lit O2
GRBS- 141 mg%
Systemic Examination:
Cardiovascular system:
S1 and S2 sounds are heard
Respiratory system:
Inspection
Shape of chest- Elliptical
B/L symmetrical chest
Trachea appears to be central
Expansion of chest equal on both sides
No accessory muscles of respiration in use
No drooping of shoulders
No wasting of muscles
No crowding of ribs
Spinoscapular distance equal on both sides
Apical impulse couldn't be seen
Palpation
All inspectory findings are confirmed
No local rise of temperature
No tenderness
Trachea central
Chest movements equal on both sides
Apex beat- Left 5th intercoastal space medial to MCL
TVF- Equal on both sides
Percussion
Direct- Resonant
Indirect- Resonant
Auscultation
BAE +
Crpets + in right IAA, ISA
Rhonchi + B/L ISA, infra SA, ICA, IAA
Abdominal Examination:
Shape of Abdomen is scaphoid
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly
Central Nervous System:
No focal neurological deficits
Provisional diagnosis
Acute exacerbation of ?Asthma ? COPD ?ILD ?Miliary TB ?CAP with Hyponatremia (Resolved) Hypokalemia(Resolving) (Hypovolemic)
with septic shock (Resolving)
HTN + since 1 year (Under Tab. Telma H stopped)
with hypothyroidism (not under medication)
Temperature charting
Investigations
4/12/22
CBP
Hb- 10.1 gm/dL
TC- 18500 cells/cumm
Platelet count- 3.32 lakhs/cumm
Blood urea- 52 mg/dL
Serum creatinine- 0.9 mg/dL
Serum electrolytes
Na+ - 123 mE/L
K+ - 3.3 mEq/L
Cl- - 82 mEq/L
Ca2+ - 0.83 mmol/L
Liver function tests
TB- 1.5 mg/dL
DB- 0.36 mg/dL
SGOT- 12
SGPT- 10
ALP- 139
Total proteins- 5.7
Albumin- 2.1
A/G ratio- 0.62
Serum uric acid- 4.7 mg%
Blood sugar random- 102 mg/dL
ABG
PH- 7.54
PCO2- 27.8 mmHg
PO2- 61.6 mmHg
HCO3- 23.8 mmol/L
O2 sat- 93.5%
Anti HCV antibodies- Rapid- Non reactive
Anti HCV antibodies- elisa- Non reactive
HBsAg ELISA- Negative
HBsAg Rapid- Negative
HIV 1 & 2 ELISA- Non reactive
HIV 1/2 Rapid test- Non reactive
Serum osmolality- 254 mOSM/Kg
Urine sodium- 125 mmol/L
Urine potassium- 26.9 mmol/L
Urine chloride- 149 mmol/L
Chest x ray PA view
ECG
2D ECHO
5/12/22
Hemogram
Hb- 9.1 mg/dL
TC- 18100 cells/cumm
PLT- 3.03 lakhs/cumm
Lipid profile
TC- 96 mg/dL
TG- 81 mg/dL
HDL cholesterol- 30 mg/dL
LDL cholesterol- 74 mg/dL
VLDL- 16.2 mg/dL
Serum electrolytes
Na+ - 127
K+ - 3.7
Cl- 91
Ca2+- 0.90 mmol/L
Thyroid profile
T3- 0.75 ng/ml
T4- 7.86 micro g/dL
TSH- 3.88 micro lu/ml
ABG
PH- 7.38
PCO2- 41.7 mmHg
PO2- 40.2 mmHg
HCO3- 24.4 mmol/L
O2 sat- 79.6 %
Blood urea- 50 mg/dL
Serum creatinine- 1.2 mg/dL
6/12/22
Hemogram
Hb- 10 mg/dL
TC- 18400 cells/cumm
PLT- 3.71 lakhs/cumm
ABG
PH- 7.432
PCO2- 32.8 mmHg
PO2- 141 mmHg
HCO3- 21.5 mmol/L
O2 sat- 97.6 %
Blood urea- 50 mg/dL
Serum creatinine- 0.9 mg/dL
Serum electrolytes
Na+ - 130
K+ - 3.4
Cl- 94
Ca2+- 0.90 mmol/L
Chest xray
7/12/22
Hemogram
Hb- 8.7 mg/dL
TC- 9000 cells/cumm
PLT- 2.91 lakhs/cumm
Blood urea- 30 mg/dL
Serum creatinine- 0.8 mg/dL
Serum electrolytes
Na+ - 133
K+ - 3.7
Cl- 99
Ca2+- 0.88 mmol/L
8/12/22
Hemogram
Hb- 7.5 mg/dL
TC- 6700 cells/cumm
PLT- 2.59 lakhs/cumm
Blood urea- 41 mg/dL
Serum creatinine- 0.8 mg/dL
Serum electrolytes
Na+ - 134
K+ - 3.6
Cl- 103
Ca2+- 0.96 mmol/L
Chest x ray
Treatment
5/12/22
1. IVF NS @ 50 ml/hr
2. Inj. PIPTAZ 4.5 g IV TID
3. O2 inhalation to maintain SPO2 > 94%
4. Inj. PAN 40 mg IV OD BBF
5. Syp. Grillintus 2 tsp BD
6. Syp. Aristozyme 5 ml BD
7. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly
8. Tab. Montek LC PO HS
9. Monitor vitals
10. Inform SOS
5/12/22
1. IVF NS @ 125 ml/hr
2. Inj. PIPTAZ 4.5 g IV TID
3. O2 inhalation to maintain SPO2 > 94%
4. Syp. POTCHLOR 15 ml/ 20 mEq in 1 glass of water PO TID
5. Inj. PAN 40 mg IV OD BBF
6. Syp. Grillintus 2 tsp BD
7. Syp. Aristozyme 5 ml BD
8. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly
9. Tab. Montek LC PO HS
10. Inj. Noradrenaline 1 amp + 44 ml NS at 5 ml/hr according to BP
11. Tab. Azithromycin 500 mg PO OD
12. Inj. Hydrocortisone 100 mg IV BD
13. Monitor vitals
14. Inform SOS
6/12/22
1. IVF NS @ 125 ml/hr
2. Inj. PIPTAZ 4.5 g IV TID
3. O2 inhalation to maintain SPO2 > 94%
4. Syp. POTCHLOR 15 ml/ 20 mEq in 1 glass of water PO TID
5. Inj. PAN 40 mg IV OD BBF
6. Syp. Grillintus 2 tsp BD
7. Syp. Aristozyme 5 ml BD
8. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly
9. Tab. Montek LC PO HS
10. Inj. Noradrenaline 2 amp + 44 ml NS at 4 ml/hr according to BP
11. Tab. Azithromycin 500 mg PO OD
12. Inj. Hydrocortisone 100 mg IV BD
13. Monitor vitals
14. Inform SOS
ICU
Day 4
S
Fever spikes -
Stools Passed +
Skin pinch normal
Cough -
O
Patient is conscious, coherent, cooperative
Temp- 98.4 F
BP- 110/60 mmHg
PR- 78 bpm
RR- 20 cpm
SPO2- 93% on RA
GRBS- 130 mg/dL
CVS- S1, S2 +
RS
BAE +
Trachea- Central
Rt. Lt
Supraclavicular. Rhonchi. Clavicular
Clavicular. Crackles, crepts. Crepts, rhonchi
Infraclavicular. Rhonchi. Rhonchi
Mammary. Crepts. Crepts&Rhonchi
Axillary. Rhonchi. Crackles
Infra axillary. Rhonchi, crackles. Crackles
Inter scapular. Crackles. Crepts, rhonchi
Infra scapular.Crackles,crepts.Crackles, crepts
P/A- Soft, Non tender
CNS- HMF+
Hemogram
Hb- 7.5 mg/dL
TLC- 6700 cells/cumm
RBC- 2.98 millions/cumm
PLT- 2.59 lakhs/cumm
Serum electrolytes
Na+ 134 mEq/L
K+ 3.6 mEq/L
Cl- - 103 mEq/L
Ca2+ - 0.96 mmol/L
A
Acute exacerbation of ? Asthma ? COPD
? ILD ? Miliary TB ? CAP
With hyponatremia (Resolved) Hypokalemia (Resolving) (Hypovolemic)
with septic shock (Resolving)
HTN+ since 1 year (Under Tab. Telma H Stopped)
With hypothyroidism (Not under medication)
P
1. IVF NS @ 100 ml/hr
2. Inj. PIPTAZ 4.5 g IV/TID (Day 4)
3. Inj. Hydrocortisone 100 mg IV BD (Day 3)
4. Inj. PAN 40 mg IV OD BBF
5. Inj. Noradrenaline 2 amp + 44 ml NS at 2 ml/hr according to BP to maintain MAP >65 if BP less than 80/50 mmHg
6. Tab. Montek LC PO BD
7. Tab. Azithromycin 500 mh PO OD (Day 3)
8. Tab. Pulmo clear 100/600 PO BD
9. Syp. POTCHLOR 20 mEq (15 ml) in 1 glass water PO TID
10. Syp. Grillinctus 10 ml PO BD
11. Syp. Aristozyme 5 ml PO BD
12. Nebulization with
Ipratropium - 6th hrly (QID)
Budecort - 12th hrly (BD)
Mucomist- 12th hrly (BD)
13. O2 inhalation to maintain saturation >90%
14. Monitor vitals
15. Strict I/O charting
16. Inform SOS
14/12/2022
ICU BED NO.1
AGE :68 GENDER :F
S
NO FEVER SPIKES
NO HYPOGLYCEMIA
O
pt is conscious
GCS- E4V5M6
B/L PEDAL EDEMA GRADE 1
BP 130/80MM HG
PR 120bpm IRREGULARLY IRREGULAR
SAT 91% ON RA ,98@2LIT O2
RR 22 CPM
GRBS-171mg/dl
CVS -S1 S2 HEARD ,NO ADDED MURMURS
P/A SOFT ,NON TENDER,BOWEL SOUNDS HEARD
CNS: NO FOCAL NEUROLOGICAL DEFECIT
RS:
BAE+
ON AUSCULTATION :
RIGHT. LEFT
SUPRACLAVICULAR. crepts. N vesicular
INFRACLAVICULAR decreased bs. N vesicular
AXILLARY. crepts. crepts
INFRAAXILLARY. fine crepts. fine crepts
MAMMARY. fine crepts NVBS
Blood urea - 54mg/dl
Serum creat -1.0 mg/dl
Serum electrolytes :
Sodium -140mEQ/dl
Pottasium - 3.2mEQ/dl
Chloride -103 mEQ/dl
Calcium ionized- 0.92mmol/L
Chest xray
ECG:
A
ACUTE EXACERBATION OF ASTHMA
with? COMMUNITY ACQUIRED PNEUMONIA ? VIRAL
with? OLD PULMONARY KOCHS
WITH HYPONATREMIA (RESOLVED) HYPOKALEMIA (RESOLVING) WITH SEPTIC SHOCK (RESOLVED)
WITH ANEMIA OF CHRONIC DISEASE
WITH BRONCHIECTASIS OF B/L LOWER LOBE AND RT MIDDLE LOBE
WITH PSVT (REVERTED) WITH ?MAT
WITH HFPEF
P
1)IVF NS @ UO+ 30ML/HR
2)INJ PAN 40 MG IV BBF
3)TAB PULMOCLEAR (100/60) PO BD
4)TAB MONTEK LC PO OD
5)SYP GRILLINCTUS Dx 2 TBSP 10 ML PO SOS
6)NEBULIZATION IPRATROPIUM-6TH HRLY , BUDECORT-12TH HRLY , MUCOMIST- 12TH HRLY
7)TAB MET XL 50 MG PO OD
8)O2 INHALATION MAINTAIN SAT > 94%
9)MONITOR VITALS AND GRBS
10)INTERMITTENT NIV 4RTH HOURLY
11)CHEST PHYSIOTHERAPY
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