80 year old male





80yr old male patient with SHORTNESS OF BREATH






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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.

A 80 year old male patient was brought to casualty(i.e4/10/2022)

CC:

Shortness of breath since 4days

Fever since 4days

Cough since 3days

Loose stools 2days


History of present illness:

Patient was apparently symptomatic 1 month back then he developed anuria for which he was admitted in a hospital for a day foleys was placed and medication was given for 10 days ,then patient developed shortness of breath four days back which was insidious in onset gradually progressed from grade 2 to grade 4 (mmrc),no postural variation ,no history of suggestive of paroxysmal nocturnal dyspnoea, chest pain ,associated with cold and cough ,cough was productive, sputum  mucoid,whitish,copious and not blood tinged and has a history of fever which was intermittent ,on and off ,no diurnal variation and associated with loose stools and burning micturition ,loose stools since two days 3 to 4 episodes per day ,non-bulky not associated with pain abdomen ,non-bloodstained .

Past history:

No similar complaints in the past

Not a know case of DM,ASTHMA,HTN,EPILEPSY,TB


Personal history:

Diet:mixed

Appetite:normal

Bowel and bladder movements:irregular (loose stools), decreased urine output since 1month

Addictions: alcohol consumption from past 30years (daily quarter) stopped 1 month back , last intake was 5 days back

          Smoking (Chutta) daily 4-5 , stopped 5 years back

No know allergies 

Family history:

No relevant family history

Fever chart:







General Examination:

Patient was not C/C/C not oriented to time,place and person

Pallor -absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

VITALS:

BP - 120/70 MM HG

PR-88 BPM

RR-27CPM

SPO2 - 97%

GRBS: 115mg/dl

TEMP - 98.2F

Systemic examination:

RS:

Inspection :

                                          R.                L

Supraclavicular area :hollow.       Normal

Infraclavicular area.  :Crowding  Normal

Position of trachea :prominent SCM on rigth side

Position of Apex beat :5 th ics

Chest : asymmetry

Increased AP diameter on left side


Palpation:

Confirmed inspiratory finding

Auscultation :
Decreased air entry on rigth side
Normal vesicular breath sounds 



CVS:

Apex beat at 5th ics at midclavicular line

 S1,S2 heard


Per abdomen: 

Scaphoid

Scar + rt side( h/o? hernia sx)

No Tenderness 
No organomegaly 

INVESTIGATIONS:

On 14/10/22 





On 15/10/22




On 16/10/22




On 17/10/22






PROVISIONAL DIAGNOSIS:

Altered Sensorium ( hypoactive) secondary  to ? Uremic Encephalopathy

T - || respiratory failure? 

Uremic Encephalopathy

Oliguric AKI (resolving)

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? MAT ? AF sinus arrhythmia 

Post dialysis done (1st - 6/10/22

2nd - 11/10/22 , 3rd - 13/10/22 , 4th - 15/10/22)


TREATMENT:

12/10/22


O:  Patient on Mechanical Ventilator 

Mode: CPAP VC

FiO2 : 30

PEEP: 7

Temp-99.5°F

BP- 90/50 MMHG

PR-67 BPM

RR-22 CPM

CVS-S1S2+

RS: BAE+ 

Crepts + Left infra axillary   added sounds @ left infclavicular, right mammary 

P?/A : soft, non- tender 

SPO2 - 98% 

GRBS: 138mg/dl

GCS: E1VTM1 


A: 

Altered Sensorium ( hypoactive) secondary to T-II respiratory failure? 

Uremic Encephalopathy

Oliguric AKI (resolving)

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? NAF With ? AF With ? BEDSORE - 2

Yesterday dialysis done (2nd session)


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ.MEROPENEM 1g/ IV/BD 

3. INJ. LASIX 80mg /IV /BD 

4. INJ NOR ADRENALINE (2amp + 46ml ns @ 5ml/hr acc to Bp 

5. INJ ATRACURIUM @ 2ml/hr

6. INJ MIDAZOLUM @ 2ml/hr

7.Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

8.TAB. AZITHROMYCIN 500mg /RT/OD 

9. TAB. DOLO 650mg/RT/SOS if temp. more than 101F 

10.Air bed 

11.Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

12.Frequent position change  

 13.Daily Bed sore dressing  

14.Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

15.GRBS charting 2nd hourly 

16. Strict I/O charting 

17.Inform SOS


13/10/22


O:  Patient on Mechanical Ventilator 

Mode: CPAP VC

GCS: E2VTM1

Temp-98.7

BP- 100/50MMHG

PR-94 BPM

RR-41 CPM

CVS-S1S2+

RS: BAE+ 

Crepts + Left infra axillary   added sounds @ left infclavicular, right mammary 

P/A : soft, non- tender 

SPO2 - 99%

GRBS: 134mg/dl


A: 

Altered Sensorium ( hypoactive) secondary to T-II respiratory failure? 

Uremic Encephalopathy

Non Oliguric AKI (resolving)

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? NAF With ? AF With ? BEDSORE - 2

Post dialysis done (1st - 6/10/22

2nd - 11/10/22)

Bed sore dressing done yesterday 


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ.MEROPENEM 1g/ IV/BD 

3. INJ. LASIX 80mg /IV /BD 

4. INJ NOR ADRENALINE (2amp + 46ml ns @ 5ml/hr acc to Bp

5.Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

6.TAB. AZITHROMYCIN 500mg /RT/OD 

7. TAB. DOLO 650mg/RT/SOS if temp. more than 101F 

8.Air bed 

9.Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

10.Frequent position change  

 11.Daily Bed sore dressing  

12.Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

13.Strict I/O charting 

14.Inform SOS


14/10/22


O:  Patient on Mechanical Ventilator 

Mode: CPAP VC

GCS: E3VTM4

Temp-99F

BP- 140/80MMHG

PR-93 BPM

RR-34 CPM

CVS-S1S2+

RS: BAE+ 

Crepts + Left infra axillary   added sounds @ left infclavicular, right mammary 

P/A : soft, non- tender , no organomegaly

SPO2 - 96%

GRBS: 99mg/dl



A: 

Altered Sensorium ( hypoactive) secondary to T-II respiratory failure? 

Uremic Encephalopathy

Oliguric AKI 

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? MAT ? AF sinus arrhythmia 

Post dialysis done (1st - 6/10/22

2nd - 11/10/22 , 3rd - 13/10/22)


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ.MEROPENEM 1g/ IV/BD in 50ml ns

3. INJ. LASIX 80mg /IV /BD 

4.Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

5.TAB. AZITHROMYCIN 500mg /RT/OD 

6. TAB. DOLO 650mg/RT/SOS 

7.Air bed 

8.Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

9.Frequent position change  

 10.Daily Bed sore dressing  

11.Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

12.Strict I/O charting 

13.Inform SOS


15/10/22


O:  Patient on Mechanical Ventilator 

Mode: CPAP VC

GCS: E2VTM1

Temp-98.7F

BP- 140/80MMHG

PR-102 BPM

RR-46CPM

CVS-S1S2+

RS: BAE+ 

Crepts + Left infra axillary   added sounds @ left infclavicular, right mammary 

P/A : soft, non- tender , no organomegaly

SPO2 - 94%

GRBS: 92mg/dl



A: 

Altered Sensorium ( hypoactive) secondary  to ? Uremic Encephalopathy

T - || respiratory failure? 

Uremic Encephalopathy

Oliguric AKI (resolving)

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? MAT ? AF sinus arrhythmia 

Post dialysis done (1st - 6/10/22

2nd - 11/10/22 , 3rd - 13/10/22)


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ.MEROPENEM 1g/ IV/BD in 50ml ns

3. INJ. LASIX 80mg /IV /BD 

4.Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

5.TAB. AZITHROMYCIN 500mg /RT/OD 

6. TAB. DOLO 650mg/RT/SOS 

7.TAB AZITHROMYCIN 500mg/RT/OD

8.TAB METXL 12.5mg/RT/OD

9.Air bed 

10.Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

11.Frequent position change  

 12.Daily Bed sore dressing  

13.Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

14.Strict I/O charting 

15.Inform SOS


16/10/22


O:  Patient on Mechanical Ventilator 

Mode: ACMV - VC

GCS: E3VTM5

Temp-98.2F

BP- 120/70MMHG

PR-88 BPM

RR-27CPM

CVS-S1S2+

RS: BAE+

Left basal crepts 

P/A : soft, non- tender , no organomegaly

SPO2 - 97%

GRBS: 115mg/dl



A: 

Altered Sensorium ( hypoactive) secondary  to ? Uremic Encephalopathy

T - || respiratory failure? 

Uremic Encephalopathy

Oliguric AKI (resolving)

with Right Upper Lobe Fibrosis ( fungal ball) ? Mass @Rt lung with ? 

Left lower lobe ASPIRATION PNEUMONIA 

With ? MAT ? AF sinus arrhythmia 

Post dialysis done (1st - 6/10/22

2nd - 11/10/22 , 3rd - 13/10/22 , 4th - 15/10/22)


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ.MEROPENEM 1g/ IV/BD in 50ml ns

3. INJ. LASIX 80mg /IV /BD 

4.Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

5. INJ ATRACURIUM (2amp+45ml NS) @ 5-10ml/hr

6. TAB. DOLO 650mg/RT/SOS 

7.TAB AZITHROMYCIN 500mg/RT/OD

8.TAB METXL 12.5mg/RT/OD

9.TAB AKT3(2tab) + pyrazinamide 750mg ( 1tab)

10.Air bed 

11.Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

12.Frequent position change  

 13.Daily Bed sore dressing  

14.Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

15.Strict I/O charting 

16.Inform SOS










 


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