68 Year old female

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Name: G Sai Manogna

Roll no: 41

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