General medicine case 7

 


A 75 year old female patient with COPD

Case

A 75 year old female patient with Shortness of breath since 2 years.

History of present illness:

Patient was apparently asymptomatic 2 years back before the standing illness.Then the patient was presented to casualty with severe shortness of breath since 7 days,fever since 10 days.

No c/o chest pain,chest tightness,haemoptysis, abdominal pain, abdominal distension.

Also cough with expectoration with scanty sputum since 4 months.

Wheezing+ve

Patient was diagnosed with asthma 2-3 years back.Medications were taken for the same.

-No H/o pedal edema

- No H/o decreased urine output

-No H/o heamaturia

-H/o loss of appetite since 4 months

-H/o weight loss.

Past history

K/c/o HTN since 5 years.
For which TELMA 40 mg  PO OD

Similar complaint in the past:2 years back.
(Seasonal variations+ve)

Patient was on betamethasone since 2 years.

No history of DM/Epilepsy/TB/Thyroid disorders

The patient had undergone tubectomy at middle age.

Personal history 

Diet : mixed
Appetite : decreased
Bowel and bladder : regular
Sleep : normal
No addictions

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

No similar complaints in the family. 

Treatment history 
Not significant. 

General examination
Patient is conscious, coherent and cooperative. 

Malnutrition+ve,mild dehydration.

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

Vitals
Temperature:98.7'F

Bp :110/70 mm hg

Pulse rate:60/min

Respiratory rate:18/min

Spo2: 98% 

Systemic examination:

CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:
JVP: normal

Auscutation:
Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-
Position of trachea: central
Dyspnoea+ve
Wheezing+ve
BAE present decreased in rt side 

PER ABDOMEN:

No tenderness.
No palpable mass.
Bowel sounds+ve
Shape of abdomen:scaphoid
No organomegaly

CENTRAL NERVOUS SYSTEM:
Patient is Conscious 

Speech: normal

Reflexes: present

Investigations:

06/10/21

CUE:
Albumin-trace
Sugars-nil
Pus cells:3-4
Epithelial cells:2-3

Blood urea:122mg/dl

Serum creatinine:2.5mg/dl

Serum electrolytes:
Na+:133meq/l
K+:4.4meq/dl
Cl-:97meq/dl

Liver function tests:
ALP:163 IU/L
SGOT:31IU/L
SGPT:16U/L
ALBUMIN:3.2 gm/dl

Urinary electrolytes:
Na+:180 mmol/L
K+:14
Cl-:212 mmol/L

07/10/21

ESR-90mm/1st hr

Spot urine protein:11mg/dl
Spot urine creatinine:44 mg /dl
Urine protein/creatinine ratio:0.25

09/10/21
Hemogram:
RBC:2.79millions/cumm
WBC:8,700 cells/cumm
PLATELETS:3.9 lakhs/cumm.
Hb:7.6 gm/dl

Reticulocyte count:0.5%

11/10/21
Hemogram:
RBC:3.0 millions/cumm
WBC:8,300 cells/cumm
PLATELETS:4.79 lakhs/cumm.
Hb:8.3gm/dl


TPR CHARTING



USG REPORT

2D ECHO REPORT


06/10/21


PROVISIONAL DIAGNOSIS-
? PRE RENAL AKI WITH COPD

FINAL DIAGNOSIS:
PRE-RENAL AKI,
ACUTE EXACERBATION of COPD,
ANAEMIA

Treatment plan

06/10/21
IVF:NS,RL @ 50 ml/ hr
Inj. Ceftriaxone 1g/iv/bd
Inj. Pan 40mg iv/OD
Inj. Zofer 4mg iv stat
Inj.optineuron 1amp iv OD
Tab.PCM 650mg po sos
Inj.lasix 40mg









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