vignesh
GENERAL MEDICINE CASE PRESENTATION
Vignesh
Roll no:- 05
3rd semester
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 also reflects patients centered learning portfolio.
●Case scenario
A 49 yr old female patient came to opd with the chief complaints of Shortness of breath(SOB) -grade IV and worsening
History of present illness
•SOB -5 to 6 months
On exertion
•Pedal edema and facial puffiness since 5 to 6 months
•Red urine output
•Fever -10 days -subside on medication-intermittent and low grade
•cough with sputum since 10 days
History of past illness
•k/c/o Hypertension-1 yr
Treatment History
Hypertension Treatment since 1 yr
•Temla 40 mg tab
Personal History
•non vegetarian
Family history
●No notable family history
Physical examination
No- pallor/Icterus/cyanosis/clubbing//malnutrition/lymphadenopathy/Mild dehydrationEdema is seen
๐๐ข๐ญ๐๐ฅ๐ฌ30/09/21• ๐๐๐ฆ๐ฉ๐๐ซ๐๐ญ๐ฎ๐ซ๐-99°๐
• ๐๐ฎ๐ฅ๐ฌ๐ ๐ซ๐๐ญ๐- 112/๐ฆ๐ข๐ง• ๐๐๐ฌ๐ฉ๐ข๐ซ๐๐ญ๐ข๐จ๐ง ๐ซ๐๐ญ๐ -28/๐ฆ๐ข๐ง• ๐๐ฅ๐จ๐จ๐ ๐ฉ๐ซ๐๐ฌ๐ฌ๐ฎ๐ซ๐-170/110๐ฆ๐ฆ๐๐ • ๐๐ ๐2%- 82%• ๐๐๐๐-187๐ฆ๐
1/10/21• BP-140/90mmHg• PR-78/min• SP O2%-94-96% on BiPAP• GRBS-132mg/dl
2/10/21
• BP- 130/90mmHg• Temperature -98.6°F -Afebrile• PR-100/min• GRBS-187mg/dl
3/10/21• BP -200/100mmhg• PR-140bpm• SP O2%-82%• Temperature-101°F• Respiratory rate-40/min
04/10/21• Temprature-afebrile• BP-130/80mmHg• PR-102bpm
๐๐ข๐ญ๐๐ฅ๐ฌ
30/09/21
• ๐๐๐ฆ๐ฉ๐๐ซ๐๐ญ๐ฎ๐ซ๐-99°๐
• ๐๐ฎ๐ฅ๐ฌ๐ ๐ซ๐๐ญ๐- 112/๐ฆ๐ข๐ง
• ๐๐๐ฌ๐ฉ๐ข๐ซ๐๐ญ๐ข๐จ๐ง ๐ซ๐๐ญ๐ -28/๐ฆ๐ข๐ง
• ๐๐ฅ๐จ๐จ๐ ๐ฉ๐ซ๐๐ฌ๐ฌ๐ฎ๐ซ๐-170/110๐ฆ๐ฆ๐๐
• ๐๐ ๐2%- 82%
• ๐๐๐๐-187๐ฆ๐
1/10/21
• BP-140/90mmHg
• PR-78/min
• SP O2%-94-96% on BiPAP
• GRBS-132mg/dl
2/10/21
• BP- 130/90mmHg
• Temperature -98.6°F -Afebrile
• PR-100/min
• GRBS-187mg/dl
3/10/21
• BP -200/100mmhg
• PR-140bpm
• SP O2%-82%
• Temperature-101°F
• Respiratory rate-40/min
04/10/21
• Temprature-afebrile
• BP-130/80mmHg
• PR-102bpm
•SYSTEMIC EXAMINATION
CVS
No Thrills
*Cardiac Sounds - S1, S2 +
*No cardiac murmurs
RESPIRATORY SYSTEM
*Dyspnoea - yes
*Yes Wheezing
*Position of Trachea - Central
*Vesicular sounds
*adventious sounds are present
ABDOMEN
*Shape - scaphoid
*No tenderness, palpable mass, No free fluid, No bruits
*Yes bowel sounds
*Hernial Orifices - Normal
*Liver, Spleen - Not palpable
CENTRAL NERVOUS SYSTEM
*Level of consciousness - conscious
*Speech - Normal
*No signs of Meningeal Irritation
*Cranial nerves - Normal
*No motor or sensory deficit
INVESTIGATIONS
2๐ซ ๐ฌ๐๐๐ ๐๐๐๐๐๐• LAD territory akinetic with RCA hypokinesia• Moderate to severe LV Dysfunction• Mild tricuspid regurgitation with mild pulmonary artery hypertension• Sclerotic AV• Transient LV dilated size-5.3cm• Diastolic dysfunction• No Pulmonary embolism /LV clot
ECG
Report
Provisional diagnosis
๐๐
๐ซ๐๐
2° ๐ญ๐จ ๐๐๐ (๐๐
-35%) CKD ( 4th stage)With ? Cardiogenic pulmonary edema (resolved)
๐๐ซ๐๐๐ญ๐ฆ๐๐ง๐ญ
30/09/21• O2 inhalation (to maintain >92%)• Nebulization with duolin and budecort -8th hourl• Inj.lasix 80mg i.v stat• Inj.Nitroglycerin 1mg in 1ml i.v stat• Inj.lasix 40mg i.v BD• Tab.Paracetamol 650mg PO, SOS• Inj.Pantop 40mg i.v OD• Inj.Zofer 4mg i.v SOS• Inj.Ceftriaxone 1g i.v BD• Tab.Ecosprin (75/20mg) PO• Monitor vitals hourly• Strict I/O charting• Foleys catheterization
01/10/21• O2 inhalation (to maintain >92%)• Nebulization with duolin and budecort -8th hourly• Inj.lasix 40mg i.v BD• Tab.Paracetamol 650mg PO, SOS• Inj.Pantop 40mg i.v OD• Inj.Zofer 4mg i.v SOS• Inj.Ceftriaxone 1g i.v BD• Tab.Met-XL 50mg PO OD• Tab.Ecosprin (75/20mg) PO• Monitor vitals hourly• Strict I/O charting• GRBS 8th hourly• Tab.Amlong 10mg PO OD-8pm
02/10/21• O2 inhalation (to maintain >92%)• Nebulization with duolin • budecort -8th hourly• Inj.lasix 40mg i.v BD• Inj.Pantop 40mg i.v OD• Inj.Zofer 4mg i.v SOS• Tab.Paracetamol 650mg PO/SOS• Tab.Met-XL 50mg PO OD• Tab.Ecosprin (75/20mg) PO• Monitor vitals hourly• Strict I/O charting• GRBS 8th hourly• Tab.Amlong 10mg PO OD-8pm• Salt restriction <2.4g/day• Water restriction 2.1L /day
03/10/21
• Dialysis• O2 inhalation @6.8L(to maintain >92%)• Inj.lasix 40mg i.v BD• Tab.Paracetamol 650mg PO/SOS• Inj.Pantop 40mg i.v OD• Inj.Zofer 4mg i.v SOS• Inj.Ceftriaxone 1g i.v BD• Tab.Met-XL 50mg PO OD• Tab.Ecosprin (75/20mg) PO• Tab.Amlong 10mg PO OD-8pm• GRBS 8th hourly
04/10/21• O2 inhalation @6.8L(to maintain >92%)• Inj.lasix 40mg i.v BD• Tab.Paracetamol 650mg PO/SOS• Inj.Pantop 40mg i.v OD• Inj.Zofer 4mg i.v SOS• Tab.Paracetamol 650mg PO/SOS• Nebulization with duolin • budecort -8th hourly• Monitor vitals hourly• Strict I/O charting• GRBS 8th hourly• Tab.Ecosprin AV (75 /25mg) PO• Tab.Nicardia PO BD• Tab.Arkamin 0.1mg PO /TID• Salt restriction <2.4g/day• Water restriction 2.1L /day
No Thrills
*Cardiac Sounds - S1, S2 +
*No cardiac murmurs
RESPIRATORY SYSTEM
*Dyspnoea - yes
*Yes Wheezing
*Position of Trachea - Central
*Vesicular sounds
*adventious sounds are present
ABDOMEN
*Shape - scaphoid
*No tenderness, palpable mass, No free fluid, No bruits
*Yes bowel sounds
*Hernial Orifices - Normal
*Liver, Spleen - Not palpable
CENTRAL NERVOUS SYSTEM
*Level of consciousness - conscious
*Speech - Normal
*No signs of Meningeal Irritation
*Cranial nerves - Normal
*No motor or sensory deficit
INVESTIGATIONS
2๐ซ ๐ฌ๐๐๐ ๐๐๐๐๐๐
• LAD territory akinetic with RCA hypokinesia
• Moderate to severe LV Dysfunction
• Mild tricuspid regurgitation with mild pulmonary artery hypertension
• Sclerotic AV
• Transient LV dilated size-5.3cm
• Diastolic dysfunction
• No Pulmonary embolism /LV clot
Report
๐๐
๐ซ๐๐
2° ๐ญ๐จ ๐๐๐ (๐๐
-35%)
CKD ( 4th stage)
With ? Cardiogenic pulmonary edema (resolved)
๐๐ซ๐๐๐ญ๐ฆ๐๐ง๐ญ
30/09/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin and budecort -8th hourl
• Inj.lasix 80mg i.v stat
• Inj.Nitroglycerin 1mg in 1ml i.v stat
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• Foleys catheterization
01/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin and budecort -8th hourly
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm
02/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin
• budecort -8th hourly
• Inj.lasix 40mg i.v BD
• Inj.Pantop 40mg i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Tab.Met-XL 50mg PO OD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm
• Salt restriction <2.4g/day
• Water restriction 2.1L /day
03/10/21
• Dialysis
• O2 inhalation @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
• Tab.Ecosprin (75/20mg) PO
• Tab.Amlong 10mg PO OD-8pm
• GRBS 8th hourly
04/10/21
• O2 inhalation @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Nebulization with duolin
• budecort -8th hourly
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Ecosprin AV (75 /25mg) PO
• Tab.Nicardia PO BD
• Tab.Arkamin 0.1mg PO /TID
• Salt restriction <2.4g/day
• Water restriction 2.1L /day
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