48 yr old male with shortness of breath
03 / 03/ 22
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A 48 year old male presented with shortness of breath.
K.Lasya Mithra, 9th semester
Roll No: 50
I have 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.
CASE:
A 48 year old male patient came to causality with
CHIEF COMPLAINT:
Shortness of breath - 3 days
Generalised edema - 3 days
History of present illness:
Pt was apparently assymptomatic 20 yrs back then he developed lower back pain for which he visited to hospital and diagnosed with renal calculi for which he used medication for 3 years and underwent sx later ,still his lower back pain didn't subcided so he visited to some rmp and used NSAIDS for 10-15 years.
3 years back one day he developed bilateral pedal edema with sob he visited to hospital and diagnosed with CKD and HTN and using regular medication with regular followup
due covid 19 lockdown he didn't had regular checkups using medication ,3 months back when he visited to hospital then he was told to have high creatinine (around 11 ,acc to patient) and need for dialysis intervention ,then he was started on dialysis .
He had 2 sessions of dialysis every week
3 days back patient developed profuse sweating, and generalised weakness , severe shortness of breath - insidious in onset and gradually progressing to grade 4 , he also complained of facia puffiness and pedal edema extending upto knee.
Past history:
He is a known case of diabetic from 10 years and on regular medication ( initially oral medication changed to insulin 3 months back)
He is also a known case of hypertension from 4 years and on regular medication
He is a known case of CKD from 5 months and on regular dialysis.
No history of asthma,epilepsy,CVD, TB
No past surgical history.
Personal history:
Appetite- decreased from 1 month
Diet- mixed
Bowel and bladder- regular
Sleep - adequate
Addictions- occasional toddy drinker
Family history: insignificant
General examination:
patient was examined in a well lit room after taking consent.
Patient is drowsy.
pallor - present
icterus - absent
Cyanosis - absent
Clubbing - absent
No lymphadenopathy
pedal edema - upto knee
Vitals: at presentation
Temperature:
BP :140/90 mmHg
PR : 98bpm
RR: 22 cpm
SpO2 90% at 15 lit of O2
Systemic examination:
CARDIOVASCULAR SYSTEM:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation, S1 S2 heard No murmurs
RESPIRATORY SYSTEM:
Trachea- central
Bilateral air entry present
Normal vesicular breath sounds heard.
PER ABDOMEN:
soft , non tender
Umbilicus - inverted
All quadrants moving equally with Respiration
No scars , sinuses, engorged veins
No palpable spleen and liver
Normal bowel sounds heard.
PROVISIONAL DIAGNOSIS :
chronic kidney disease secondary to diabetes and k/c/o hypertension.
INVESTIGATIONS:
CBP:
Hb - 5.1 gm/dl
TLC - 11400 cells/ cumm
RBC - 1.7 million
PLT - 1.5 lakh
PCV- 15
RFT:
urea - 109 mg/dl
Creatinine - 3.8 mg/dl
Uric acid- 5.8 mg/dl
Electrolytes:
Na - 145 mEq/L
K - 3.7 mEq/L
Cl - 104 mEq/L
LFT :
Total bilirubin- 2.3 mg/dl
ALT - 15 IU/L
AST - 31 IU/L
ALP - 240 IU/L
albumin - 2.1 gm/dl
A/ G ratio - 0.68
ABG:
Date pH pCO2 HCO3
26/02 7.4 36.1 23.8
27/02 7.4 33 22.8
28/02 7.4 33 21.5
01/03 7.3 43 20.8
02/03 6.9 69.4 16.2
ECG:
Treatment:
02/03
1) Fluid restriction - <1.5 lit /day
2) salt restriction - <2 gm/day
3) Inj. LASIX - 40 mg , IV , TID
4) Tab. NICARDIA - 20 mg , BD
5) Tab. ARKAMINE - 0.1 mg , TID
6) Tab. NODOSIS - 500 mg , BD
7) Tab. OROFER , BD
8) Tab. SHELCAL - 500 mg , OD
9) Tab . BIO D3 - 0.25 mcg , OD
10) Iron sucrose - 1000 mg in 100 ml NS over 1hr
11) Erythropoiten - 4000 units, SC , once weekly
12) Tab. PAN - 40 mg , IV, BD
13) Tab. ZOFER - 4 mg , IV, TID
ABG:
Time pH pCO2 HCO3
10 pm 6.9 69.4 16.2
10:30 pm 7.3 60 21.7
Patient had cardiac arrest (due to severe acidosis) and cpr was done. Patient revived after 2 cycles of cpr.
Post cpr patient is on mechanical ventilation.
X- RAY
03/03
Patient on MV -ACMV-VC
FiO2-40
Vt-400
PEEP: 6
Vitals:
Temp:101°F
BP:170/100 mmHg
PR: 124 bpm
RR:16cpm
Spo2 : 98%
GRBS: 360 mg/dl
On examination:
CVS:S1S2+
RS: BAE+
P/A: Soft
CNS: E1VTM1
ABG:
Time pH pCO2 HCO3
8:00 am 7.5 22.7 17.8
4:00 pm 7.5 20.9 17.1
8:00 pm 7.5 27 22.4
Treatment:
1) Fluid restriction - <1.5 lit /day
2) salt restriction - <2 gm/day
3) Inj. LASIX - 40 mg , IV , TID
4) Tab. NICARDIA - 20 mg , BD
5) Tab. ARKAMINE - 0.1 mg , TID
6) Tab. NODOSIS - 500 mg , BD
7) Tab. OROFER , BD
8) Tab. SHELCAL - 500 mg , OD
9) Tab . BIO D3 - 0.25 mcg , OD
10) Iron sucrose - 1000 mg in 100 ml NS over 1 hr
11) Erythropoiten - 4000 units, SC , once weekly
12) Tab. PAN - 40 mg , IV, BD
13) Tab. ZOFER - 4 mg , IV, TID
14) Tab. METOZ - 5 mg, OD
15) RT Feeds - 100ml milk with protein powder , 3rd hrly
16) Neb. DUOLIN - 8th hrly, BUDECORT - 12th hrly
17) Tab. DOLO - 650 mg , QID
18)Inj. AUGMENTIN - 1.2 gm, IV, TID
04/03
Patient on MV -ACMV-VC
FiO2-35
Vt-400
PEEP: 5
Vitals:
Temp:101°F
BP:160/90 mmHg
PR: 124 bpm
RR:16cpm
Spo2 : 98%
GRBS: 360 mg/dl
On examination:
CVS:S1S2+
RS: BAE+
P/A: Soft
CNS:E2VTM1
ABG:
Time pH pCO2 HCO3
8:00 am 7.4 38.8 27.4
Diagnosis: Type 2 respiratory failure,post cpr status, k/c/o - diabetic nephropathy, HTN
Treatment:
1) Fluid restriction - <1.5 lit /day
2) salt restriction - <2 gm/day
3) Inj. LASIX - 40 mg , IV , TID
4) Tab. NICARDIA - 20 mg , BD
5) Frequent change of posture
6) Tab. NODOSIS - 500 mg , BD
7) Tab. OROFER , BD
8) Tab. SHELCAL - 500 mg , OD
9) Tab . BIO D3 - 0.25 mcg , OD
10) Iron sucrose - 1000 mg in 100 ml NS over 1 hr
11) Erythropoiten - 4000 units, SC , once weekly
12) Tab. PAN - 40 mg , IV, BD
13) Tab. ZOFER - 4 mg , IV, TID
14) Tab. METOZ - 5 mg, OD
15) RT Feeds - 100ml milk with protein powder , 3rd hrly
16) Neb. DUOLIN - 8th hrly, BUDECORT - 12th hrly
17) Tab. DOLO - 650 mg , QID
18)Inj. AUGMENTIN - 1.2 gm, IV, TID
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