General medicine case 6

 Sep 4th,2021

 

A 49 year old female patient 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."


Date of admission:29/09/2021

Case

A 49 year old female patient with Shortness of breath, facial puffiness, pedal edema, fever since 3 months.

History of present illness

Patient was apparently asymptomatic 3 months back before standing illness.Then the patient was admitted to the Casualty with the chief complaints of Shortness of breath, facial puffiness,pedal edema and fever since 3 months.

Patient had noticed significant decrease of breathing rate one night where she rushed to a hospital in nalgonda.There it was told that patient had two damaged kidneys and was diagnosed with high blood pressure.
Medications were taken for the same and there was symptomatic relief of SOB.

But,after 3-4 days patient again had severe shortness of breath and was rushed to govt. hospital in nalgonda where it was suggested to kims.

Patient had decreased urine output a day before admission to the Casualty.

She had intermittent and low grade fever which subsided on taking medication.

Patient c/o cough associated with sputum;scanty since 10 days.

Got vaccinated 8 days back.

Past history:

H/o HTN since 1 year.
No history of DM/Epilepsy/TB/Thyroid disorders
H/o kidney disease 5-6 years back but not on any medication.
The patient had not undergone any surgeries.

Personal history 

Diet : mixed
Appetite : normal (according to patient's wife)
Bowel and bladder : normal 
Sleep : disturbances

Family history
No history of DM/CVA/CAD/Asthma/thyroid disorders

No similar complaints in the family previously. 

Treatment history 

Patient was on antibiotics.

Physical examination:

A.General examination
Patient is conscious, coherent and co-operative.

No pallor,no icterus,no cyanosis,no clubbing,no lymphadenopathy. 

Vitals
Bp :170/110mm hg
PR: 112bpm
Respiratory rate:28/min
Temperature:98.5'F
Spo2:82%
GRBS:187mg%

B.Systemic examination:

CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge.

Palpation:
JVP: normal

Auscutation:
Normal with regular heartbeat
S1, S2 heard
No murmurs 

RESPIRATORY SYSTEM-
Position of trachea: central
Dyspnoea+ve
Wheezing+ve
Breath sounds: vesicular

PER ABDOMEN:
Normal. No mass is palpable. 
No organomegaly
Liver and spleen:non palpable

CENTRAL NERVOUS SYSTEM:

Patient is conscious.
Speech:Normal.

Investigations:

30/09/2021
Hemogram:
RBC:2.95millions/cumm
WBC:13,300cells/cumm
PLATELETS:3.41 lakhs/cumm.
Hb:8.2 gm/dl

Liver function tests:
SGOT:34 IU/L
SGPT:27 IU/L

Renal function tests:
Urea:161 mg/dl
Creatinine:10 mg/dl

Serum electrolytes:
Na+:130meq/l
K+:40meq/dl
Cl-:90meq/dl

04/10/2021
Hemogram:
RBC:2.59millions/cumm
WBC:19,500cells/cumm
PLATELETS:1.57 lakhs/cumm.
Hb:7.2 gm/dl

Renal function tests:
Urea:44 mg/dl
Creatinine:3.3 mg/dl

Serum electrolytes:
Na7.9meq/l
K+:2.6meq/dl
Cl-:97meq/dl

ABG:
PH:7.27
Pco2:25.6mmhg
Po2:152mmhg
Hco3:11.6mmol/L

SEROLOGY : negative. 

ULTRA SOUND :

Left simple renal cyst. 

2D-ECHO:

Moderate to severe LV dysfunction 

ECG:
30/09/21

03/10/21

TPR CHARTING:



USG report:

PROVISIONAL DIAGNOSIS:

HFrEF secondary to? CAD ( EF - 35%) ( LAD - Akinesia). 

-? CKD ( stage 5.) 

-? Cardiogenic pulmonary edema.

Treatment:

30/09/21
IVF:NS,RL @ 50 ml/ hr
Inj. Ceftriaxone 1g/iv/bd
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Tab. Pcm 650 mg po/sos
Inj.lasix 40mg
T .ecosprin AV

01/10/21
O2 inhalation @6.8 lit/min
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Tab. Pcm 650 mg po/sos
Inj. Ceftriaxone 1g/iv/bd
Inj.lasix 40mg
T .ecosprin AV
T.met XL 50mg/PO/OD
Monitor vitals hrly
GRBS 8th hrly
T. Amlong 10mg /PO/OD

02/10/21
O2 inhalation (maintain >92%)
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Tab. Pcm 650 mg po/sos
Inj. Ceftriaxone 1g/iv/bd
Inj.lasix 40mg
T .ecosprin AV
T.met XL 50mg/PO/OD
T. Amlong 10mg /PO/OD
Monitor vitals hrly
Strict I/O Charting
Salt restriction <2.4 g/day
Water restriction <1 lit /day

03/10/21
O2 inhalation (maintain >92%)
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Tab. Pcm 650 mg po/sos
Inj. Ceftriaxone 1g/iv/bd
Inj.lasix 40mg
T .ecosprin AV
T.met XL 50mg/PO/OD
T. Amlong 10mg /PO/OD
Monitor vitals hrly
Strict I/O Charting
Salt restriction <2.4 g/day
Water restriction <1 lit /day
T.Nicardia 20mg/PO/BD








-Why does heart failure causes facial puffiness?
-What is the role of BNP TESTING in Heart failure ???
-What does high BUN and creatinine ration indicates???
-What are the medications that cause increased BUN Levels?
-What are the medications to be taken for high creatinine levels?









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