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









Comments

Post a Comment

Popular posts from this blog

Final short case

Image
  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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT  February 1 2022 ( date of admission) A 13 year old female came to OPD with complaints of abdominal pain since 2 days associated with two episodes of vomitings HISTORY OF PRESENTING ILLNESS - Patient was apparently asymptomatic 2 days ago then she developed epigastric pain which is severe and radiating ,gradually progressive, 2 episodes of vomiting since 2 days with food as content . PAST HISTORY -  K/C/O sickle cell anaemia since 2012   History of bronchopneumonia History of sickle cell crisis 2016 Hitory of pancreatitis 2019 Last blood transfusion 2020 PERSONAL HISTORY : DIET - MIXED, APPETITE -NORMAL , BO
Read more

General medicine case 11

Image
  A 53 year old male patient with Shortness of breath, difficulty in swallowing and headache "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." Case: A 53 year old male patient with Shortness of breath, difficulty in swallowing and headache since 1 month. History of present illness: Patient was apparently asymptomatic 3 years back before the standing illness.Then the patient experienced shortness of breath, difficulty in swallowing and headache since 30 days for which he was admitted into the hospital. It all started 3
Read more

General medicine case 4

Image
45 YEAR OLD PATIENT WITH ALTERED SENSORIUM  Sep 20,2021 *ICU admission under Unit 6* "The patient history was taken from the psychiatry notes written by Dr.Raghunath sir,Dr.Somera mam and Dr.Manasa mam". "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." CASE: A 45 year old patient farmer by occupation was presented to the Casualty with chief complaint of altered sensorium since 1 week secondary to hyponatremia?? Alcohol withdrawal?? History of present illness: Patient was apparently asymptomatic 1 week back
Read more