80 year old male with history of SOB since 3 days
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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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY ATTENDERS
A 80 year old male came to the causality on Friday morning with Cheif complaints of
★ Shortness of breath since 3 days
★ altered sensation since 3 days
History of present illness
The patient was apparently asymptomatic 1 month back then he developed generalized weakness which was incidious in onset because of that he can't able to walk so he is on bed. Then 3 days ago attendees noticed that patient was tachypneic and doing mouth breathing and was taken to local RMP and told to have BP 200/100 and was brought to local hospital with complaints of altered sensorium -not speaking,responding to commands since 3 days. No complaints of fever, seizures,headache,decreased UO,pedal edema.
15 years back he stopped working
2 years back his 2nd daughter died he was in that depression for few months
1 and half year back he was admitted in our hospital and diagnosed as metabolic encephalopathy ( resolved)
5 months back he had alteredsensorium and treated under op basis
Hospital stay
Admitted on 2/12/22 in the morning With tachypnea, tachycardia( 135 BPM) , and was intubated after 10 min he had an cardiac arrest , after doing CPR for 2 min he retrived back from then bought to ICU and kept on Inotropes even though he is having hypo tension from then.
On ABG it shows acidosis so dialysis was done at 5 30 pm during dialysis his SBP was around 110 , 90, 100 around that.
Today morning the patient is having atrial fibrillation so midazolam was given and his heart ratecame back to normal
Past history
No h/o diabetes , hypertension , epilepsy , TB , asthma
H/o hernia surgery nearly 3 years back
Past discharge summary
Personal history
Mixed diet
Appetite decreased
Bowel and bladder : involuntary since 3days
Sleep : adequate
Addictions : he was a smoker and alcoholic back then
he stopped smoking and alcohol 10 yrs back
Family history history.
Not significant
General phycial examination
The patient was examined in a well lighted room
The patient was unconscious and under sedation thin built and nourished
Pallor - present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals at 4pm on ventilator
Temperature : 98.6 ° F
BP : 70/50
PR :100 bpm
RR :14 cpm
SpO2 : 98 % with 100 fiO²
GRBS : 113 mg/dl
Vitals at
Systemic examination
Respiratory :
Inspection :
No visible scars and sinuses
Some hypopigmented spots are present
Chest appears bilateral symmetrical and elliptical in shape
Trachea is central in position with endotracheal tube in it
No dilated veins
And is having central line
Palpation : all inspectory findings are confirmed
Apical impulse is felt in 5th intecostal space
On percussion
Right Left
Supra
Clavicular (R) (R)
Infra (R) (R)
Clavicular
Mammary. dull
Inframamary. Dull
Axillary. dull
Infra axillary. dull
Auscultation:
Crepts ad heard in IMA, IAA , ISA
CNS
Patient is unconscious
And is on sederion at 4 pm
And at the time of admission CNS findings
GCS : E2V1M1 ( 4/15 )
Pupils : b/l nsrl
Tone : normal in all 4 limbs
Power : not elisitable
Reflexes :
(R). (L)
Biceps 1+. 1+
Triceps 2+. 1+
Supinator 1+. -
Knee 1+. 2+
Ankle 1+. 1+
Plantar Mute Flexion
Abdomen :
On inspection
Shape : scaphoid
Umbilicus : central , inverted
Equal movements in all quadrants with desperation
Visible pulsations seen under xiphoid sternum
A healed scar is present in left iliac fossa
No sinus
No localized swellings
On palpation
No masses palpated
No organomegaly
On purcussion
Tympanic note is seen
On auscultation
Bowel sounds are heard
No local lymphadenopathy
PROVISIONAL DIAGNOSIS
Acute Pulmonary edema with uremic encephalopathy with ? Chronic kidney injury
Investigations
1/02/2022
ABG at 12 pm (2/12/22)
Serial ecgs
Bed side 2d echo
Concentric LVH
Sclerotic thickening of AV
No pulmonary embolism
Air bed
Inj.Atracurium 5ml/hr(undiluted)
Inj.Medazolam 5ml/he
Inj NORAD 15 ml/ hr acc to MAP
RT feeds 100ml milk + protein powder 4th hrly,200 mo free water 4th hrly
Inj. Pantop 40mg iv OD
Tab.NODOSIS 500 mg RT/TID
Tab. Shelcal RT/OD
Cap bio D3 RT OD weekly once
Inj lasix20mg iv BD
GRBS 4th hrly monitoring
Inj NaHCO3 100 mg +100 ml NS
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