A 48 YR OLD MALE WITH SHORTNESS OF BREATH
"This is an 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 patient's clinical problems with collective current best evidence based inputs.This elog also reflects my patient-centered online learning portfolio and your valuable inputs are welcome on the comment box "
22nd December 2021
Name : G Meghana
Roll.no :161 ( 9th semester )
CASE :-
A 48 yr old male patient,farmer by occupation came to the OPD with chief complaints of :
- Shortness of breath which aggravated since 2 hrs
- indigestion since a day
- pedal oedema since 1 month
- productive cough since a week
History of present illness :-
- The patient was apparently asymptomatic 1 month ago , then he noticed swelling in both his legs which was gradually progressive extending upto his knees .
🠇
- The patient noticed difficulty in breathing following exertion since a few days and disturbance in sleep sometimes due to dyspnea
🠗
- He had history of productive cough since a week
🠋
- A day ago the patient visited a family function and after dinner , the patient started to experience indigestion and Shortness of breath , the patient was taken to a local RMP who had given him some medication. It aggravated to GRADE 4 within 2 hours , associated with orthopnea and PND
🠗
-The patient fell to the ground unable to breathe and was brought to our hospital at 2 am on 19/12/2021 and admitted to ICU
🠗
- No history of decreased urine output.
No H/O facial puffiness
No H/O fever or cold
PAST HISTORY :-
- No similar complaints in the past
- He is not a k/c/o DM, HTN, TB, jiBA, EPILEPSY, CVD.
PERSONAL HISTORY :-
Diet - Mixed
Appétite - Reduced
Sleep - Distubed
Bowel and bladder movements- Normal
Addictions - Patient smokes 3-4 cigarettes per day since past 15 yrs
- he consumes alcohol occasionally
Allergies - not known
FAMILY HISTORY:-
His mother is a known case of DM and HTN
GENERAL EXAMINATION:-
- The patient was conscious, coherent and cooperative and examined after having taken his informed consent .
His VITALS were :- Temp - 97.3 F
- BP: 170/120 mm Hg
- Pulse Rate : 126 bpm
- Respiratory Rate :34 cpm
- GRBS : 206 mg/dl
- SpO2 at room air : 83%
PHYSICAL EXAMINATION:-
- Pallor - absent
- Icterus - absent
- Cyanosis - No
- Clubbing - No
- Lymphadenopathy - not seen
- Oedema - pedal oedema ( pitting type )
SYSTEMIC EXAMINATION:-
CVS : S1 and S2 heard
No murmurs or thirlls heard
RESPIRATORY SYSTEM:-
BAE +
ISA and IAA inspiratory crepts +
B/L ISA Wheeze +
Dyspnea +
PER ABDOMINAL EXAMINATION:-
soft , non tender , no organomegaly seen
No free fluid , hernial orifices or palpable masses felt
CNS :-NAD
CLINICAL IMAGES :-
B/L pitting oedema :
INVESTIGATIONS :-
On 19/12/21
Chest XRay
Lungs show sign os of mild pleural effusion
ECG :-
Minor ST T abnormalities
Short PR interval
Tachycardia
Ultrasound scan :-
B/L mild pleural effusion
PROVISIONAL DIAGNOSIS :-
B/ L mild pleural effusion
Community Acquired Pneumonia
Exacerbation of COPD (?)
Heart Failure (?)
TREATMENT :-
On 19/12/21 :-
- Nebulisation
- inj LASIX 40 mg IV stat given
- inj. PANTOP 40 Mg IV Stat given
- inj Augmentin 1.2 gm IV BD
- Nebulisation IPRAVENT ,BUDECORT - 6 th hrly
- GRBS monitoring 6 th hrly
- BP , PR monitoring 2 hrly
- Tab ecospirin (75 mg ) OD
- Fluid and salt restriction
- Tab Telma H (40 mg ) OD
UPDATE ON 20/12/21 :-
Inj PANTOP. 40 mg IV OD
Inj LASIX 40 mg IV TID
Tab ECOSPIRIN 75 mg OD
Tab MET XL 2 mg OD
Tab Azithro 500 mg OD
Syp.Ascoril
Nebulisation IPRAVENT
BUDECORT 6 th hrly
Inj . Augmentin 1.2 gm BD
On 21/12/21 (UPDATE )
Inj PANTOP. 40 mg IV OD
Inj LASIX 40 mg IV TID
Tab ECOSPIRIN 75 mg OD
Tab MET XL 2 mg OD
Tab Azithro 500 mg OD
Syp.Ascoril
Nebulisation IPRAVENT
BUDECORT 6 th hrly
Inj . Augmentin 1.2 gm BD
The patient was discharged on 21/12/21 on request in the evening
Comments
Post a Comment