70 year old female with SOB
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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, and investigations, and come up with a diagnosis and treatment plan.
CASE PRESENTATION
Patient came to the casualty with the complaints of breathlessness since since 10 days
Complaints of swelling of both the legs since 10 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days back then she had fever for 1 day which is high grade, sudden onset, associated with chills and rigors, relieved by taking medication. SOB (grade-II) since 10 days which is gradually progressive and Progressed to grade-IV. No orthopnea, No PND.
C/o pedal Edema which is pitting type.
C/o itchy scaly lesion dorsum of foot since 1 year.
H/o Burning micturition for 3 days.
No H/o decreased urine output.
No H/o cough, cold
No H/o chest pain, palpitations
No H/o abdominal pain, nausea, Vomiting, loose stools
PAST HISTORY:
K/C/O HTN since 4 years
Not a K/C/O DM, TB, Epilepsy, CVA, CAD
PERSONAL HISTORY:
Takes mixed diet, normal appetite
Sleep adequate
Burning micturition since 2 days
Addictions: Drinks Whisky 90ml everyday.
Stopped 10 days back
No Significant Family History
O/E:
Patient is c/c/c
Mild Pallor+
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
Edema of feet present
Vitals:
Temp: 98.8F
BP: 180/100mmhg ---> 150/100mmhg
PR: 110bpm
RR: 32cpm
Spo2: 85% at RA
GRBS: 111 mg/dl
CVS: S1 S2 heard, No murmurs
RS: BAE present, No added sounds
P/A: soft, non tender, bowel sounds heard
CNS: NFND
Nephrologist opinion was taken on 06/04/23 i/v/o deranged RFT
Adviced-
-Inj. Lasix 40mg IV TID
-T. Nodosis 500mg PO BD
Dermatologist opinion was taken on 07/04/23 i/v/o itchy lesion over the feet and lower limbs since 1 year.
Diagnosed as Nummular Eczema
Adviced-
-Liquid Paraffin L/A BD X 2 weeks
-Momate cream L/A OD X 2 weeks
-T. Teczine 5mg PO/SOS
INVESTIGATIONS:
RBS- 108mg/dl
Blood Urea- 163mg/dl
S. Creatinine - 5.6mg/dl
ECG-
USG Abdomen findings -
- Moderate B/L pleural effusion
- Raised echogenicity of B/L kidneys
- Right simple renal cortical cyst
X-Ray -
DIAGNOSIS:
CAD - NSTEMI
HFPEF (56%)
Non oliguric AKI on CKD secondary to ?Hypertensive nephropathy ?NSAIDS
Nummular eczema
? Eczema secondary to varicose veins
B/L pleural effusion Transudative lymphocytic predominant secondary to CHF
? COPD
K/C/O HTN since 4years
TREATMENT:
-Inj. Sodium bicarbonate 50mEq IV STAT for 10-15 mins
-Inj. Sodium bicarbonate 50mEq IV STAT in 100ml NS
-Inj. Lasix 40mg PO BD
-Inj. Heparin 4000IU IV QID
-Inj. Neomol 1gm IV SOS
-Tab. Ecosprin Gold 75/20/75 PO HS
-Tab. Ecosprin AV 70/20 PO HS
-Tab. Cardivas 3.125mg PO OD
-Tab.Isosorbide nitrate + Hydralazine 20mg+37.5mg PO/OD
-Tab. Hydrated Di- Hydralazine 12.5mg PO/OD
-Tab. Nicardia 20mg PO STAT
-Tab. Cinod 10mg PO OD
-IV Fluids @ 75ml/hr
-Tab. NODOSIS 500mg PO/BD
-Liquid Paraffin L/A BD
-Momate cream L/A OD
-T. Teczine 5mg PO/SOS
-T. Dolo 650mg PO/TID
-Syp. Citralka 15ml PO TID in 1 glass of water
-Protein X Powder in 200ml of milk/water PO BD
-Nebulization with Salbutamol 6th hourly
-Strict I/O charting
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