A CASE OF 42 YEAR OLD FEMALE WITH SOB AND COUGH

A 42 year old female patient came to casuality on 15/12/21 with c/o SOB Since 3 months, cough since 10 days,Fever since 7 days and decreased urine output since 2 days.

History of presenting illness:

Patient was apparently asymptomatic 3 months back after which she developed SOB which was insidious in onset (grade 2 to 3 ), progressive in nature a/w Wheeze and orthopnea.

C/o cough since 10 days with expectoration (mucoid, minimal, foul smelling and not blood stained) increased on lying down and decreased when sitting down

- c/o fever since 7 days, insidious in onset a/w chills

- c/o decreased urine output since 2 days 

- No c/o chest pain/ myalgias/ loss of taste or smell/ pnd.

- h/o TB 10 years back ( took ATT for 6 months )

- h/o similar complaints for the past 6 months (on inhalation since 10 days SOS )

- not a k/c/o DM/ HTN/ IHD.

- h/o biomass exposure for 25 years.

Patient was admitted under pulmonology department for the above complains initially where she was intubated ( on 17/12/21) and then was shifted to medicine on 19/12/21 icu i/v/o increased heart rate and 2D ECHO findings.

On 19/12/21 one whole Blood transfusion was done(2 FFP+ 1 PRBC)

2D ECHO findings:

ON 17/12/21

Mild LVH, moderate PAH with RVSP = 70 mmhg

Good LV systolic function and EF=60%

Diastolic dysfunction present and minimal PE 

Dilated RA/RV and IVC.

ON 20/12/21

LAD territory akinetic and mild LV dysfunction (EF=45%)

Moderate TR and PAH (RVSP=65 MMHG)

Dilated RA/RV/IVC

Mild extent MR+

Mild AR +

Sclerosis AS+

Diastolic dysfunction present

General examination

Patient was consious and cooperative

No signs of pallor, cyanosis, clubbing, koilonychia, edema.

Vitals:

Temperature: afebrile

Pr: 120 bpm

Rr: 39cpm

Bp: 140/90 mmhg

Grbs: 141 mg/dl

RS: BAE+ B/L crepts heard at SSA, IAA,ICA,MA

Cvs: s1 and s2 heard

P/A : soft

Investigations on admission: 

Hb: 12.3

Tlc: 24000

Plt. Count: 4.40

LFT:

TB: 1 54

DB: 0.40

AST: 48

ALT: 41

ALP: 351

TP: 7.5

ALB: 3.4

RFT:

UREA: 35

CREAT: 1.0

UA: 7.5

Ca2+ : 10.0

Na+ : 140

K+ : 3.7

Cl- : 92

K+ : 3.7

 

ABG:

PH: 7.32

PCO2: 119

PO2: 67.4

HCO3- : 60.0

St. HCO3- : 52.1

16/12/21

ABG:

PH: 7.34

PCO2: 94.6

PO2: 81.8

HCO3-: 50.3

St.HCO3- : 44.9

Hb: 9.6

Tlc: 14200

Plt count: 3.34

17/12/21:

Na+: 145

K+: 4.2

Cl-: 93

ABG:

PH: 7.35

PO2 : 84.9

PCO2: 77.7

HCO3-: 42.6

St. HCO3-: 38.3

Na+: 145

K+: 3.7

Cl-: 92

Urine for ketone bodies: negative 

Blood urea : 29

Cretainine: 0.6

Ecg:

18/12/21

D dimer:  2650

LFT:

TB: 1.80

DB: 0.40

AST: 58

ALT: 20

ALP: 153

TP: 6.0

ALB: 2.8

Troponin: negative

Blood sugar: 87 (fbs)

CBP

Hb: 9.7

Tlc: 9200

Plt. Count: 2.45 

Bt: 2 min

Ct: 4 min

Pt: 20 sec 

Aptt: 39 sec

ABG:

PH: 7.50

PO2 : 55.4

PCO2: 27.6

HCO3-: 21.5

St. HCO3-: 24.2

Blood group : B positive 

Xray 8 am

xray 11 pm

Ecg at 10 50am

Ecg at 7 20 pm

 

CT:

19/12/21

Hb: 9.2

Tlc: 13800 

plt. Count: 1.57

RFT:

Urea: 44

Creatinine: 0.5

Uric acid: 2.0

Ca2+: 9.2

PO4-3: 2.5

Na+ : 143

K+: 3.5

Cl- : 98

 Ecg at 5 30 am

Ecg at 10 50am 

20/12/21

ABG:

PH: 7.45

PCO2: 46.8

PO2: 198

HCO3-: 32.6

St.HCO3-: 31.8

Ecg:

Provisional diagnosis:

Acute exacerbation of brochiectasis with type 2 Respiratory failiure with PAH with B/L fibrosis with post TB sequelae.

Treatment

1. INJ. PIPTAZ 4.5 GM IV TID

2. TAB. AZITHROMYCIN 500MG OD

3. INJ. HYDROCORT 100MG IV TID

4. INJ. LASIX 20MG IV BD if sbp more than 110 mmhg

5. O2 inhalation at 6 to 8 liters per min

6. NIV with BIPAP continuously with 2 hours gap after meals

7. Neb. With duolin 4th hourly and budecort 8th hourly and mucomist 2nd hourly 

8. Syp. AROSTOZYME 2tbsp TID

9. Syp. ASCORYL 2 Tbsp TID

10. T. PCM 650MG SOS 

11. Inj. PAN 40 mg IV BD

TREATMENT IN MEDICINE DEPARTMENT 

1. 1 WHOLE BLOOD TRANSFUSION 

2. INJ. MIDAXOLAM AT 6 MG/HR

3. INJ. PANTOP 40MG IV OD

4. INJ. PIPTAZ 4.5 GM IV TID

5. T. AZITHROMYCIN 500MG IV BD RT

6. INJ. HYDROCORT 100MG IV BD 

7. INJ  TRANEXA 500MG IV BD

8. INJ. VIT K 10MG IN 100ML NS IV STAT

9. T. SILDENAFIL 20MG RT TID

10. IVF NS RL AT 75 ML/HR

11. AIR/ WATER BED

12. INJ. VASOPRESSIN 1 AMP IN 50 ML NS AT 1.6 ML/ HR 

13. INJ. CLINDAMYCIN 600 MG IV TID 

14. ET SUCTUON + ORAL SUCTION HOURLY.

Soap notes 22/12/21

S - fever spikes+

O- Pt is on mechanical ventilation(intubated on 17/12/21)

Under sedation

Acmv vc mode fio2- 70

Peep- 4, vt- 360, RR- 18,I:E-1:2.3

Temp- 100f

Bp- 120/70mmhg on inj noradrenaline @5ml/hr

Inj vasopressin @0.5ml/hr

PR- 94bpm

RR- 18cpm

Spo2- 97% with fio2-60

Grbs- 160mg/dl

I/o- 1000ml/1100ml

Rs- bae+, inspiratory crepts + at infrascapular and inframammary area

Cvs -s1s2+

P/a - soft ,bs+

Cns - E1VtM1

Pupils - b/l reacting to light

Corneal present

Conjuctival - present

Dolls eye- present

A - acute exacerbation of copd with type 2 respiratory failure 

Severe PAH type 2

Post pulmonary kochs sequale 

Denovo HTN

Heart failure with preserved ejection fraction (ef-45%) 

P- tapering the ionotropes dosage, stop sedation and check for response 

Inj piptaz4.5gm iv tid

Inj clindamycin 600mg iv tid

Inj pantop 40mg iv od

Ivf NS RL @75ml/hr

Neb with ipravent 8thhrly

Budecort 8thhrly

Oral and et suction 2nd hrly 

Chest physiotherapy

A CASE OF 45 YEAR OLD FEMALE PATIENT WITH SOB, FEVER, PAIN ABDOMEN AND GENERALISED WEAKNESS.

A 45 year old female came to the OPD with the C/O Fever since 3 days

HOPI:

Pateiny came with c/o fever since 10 days

Generalised body pains since 10 days 

Pain abdomen since 5 days 

History of presenting illness:

Patient was apparently normal ten days back then she developed fever, low grade associated with chills and rigors not associated with cough, no burning micturiation, no vomitings, no loose stools. Fever subsided after medication 5 days back 

Then since 5 days patient developed pain abdomen around umbilicus and epigastrium, non radiating associated with SOB grade 3 and 4, not associated with nausea and vomiting, loss of appetite

History of past illness:

Not a K/C/O HTN/DM/TB/Epilepsy/Asthma/CAD/CVA

Patient was hysterectomised 15 years ago

Family history - Not Significant

Personal History:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

No addictions

General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp - 100 F

PR- 120 bpm

BP- 90/60 mmHg

RR- 40 cpm

SpO2- 97% at RA

Fever chart:

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+ , B/L IAA, IMA crepts

CNS- NAD

P/A- Soft, Non-tender

Provisional diagnosis:

Viral Pyrexia with Thrombocytopenia, viral pneumonia, sepsis with MODS.

Investigations on admission:

Cue:

Albumin +

Ec : 2 to 3

Pc : 3 to 4

BS : negative

BP: negative

Sugar : negative

Blood cells and casts : negative

Blood urea: 90

Serum creatinine:  1.1

Na+ : 139

K+ : 4.8

Cl- : 95

LFT:

TB: 7.01

DB: 3.10

AST: 111

ALT: 75

ALP: 403

TP: 6.3

ALB: 2.0

ABG: 

PH: 7.37

PCO2 : 53.3

PO2 : 38.1

HCO3- :30.3

ST. HCO3- : 26.7

MP: negative

HIV : Negative

HBSAG : negative

HCV : negative

RAPID DENGUE : negative

RTPCR : negative

Ecg:

2d echo:

usg:

Xray:

Ecg on 18/12/21

Review usg:

Investigations on 19/12/21

Hb: 9.3

Tlc: 20,800

Plt. Count : 3.73

Serum total bilirubin: 9.92

Direct bilirubin: 3.21

Serum creatinine : 0.7

Xray

Plan of treatment 

1. Ivf NS/RL/DNS continuous at 100ml/hr

2. Inj. PAN 40mg IV BD 

3. inj. ZOFER 4mg IV/SOS

4. Inj. NEOMOL 1gm IV/SOS

5. Inj. PIPTAZ 4.5 gm IV TID

6. Tab. PCM 650 mg PO/ SOS

7. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD

8 Tab. TUSQ 1 tab PO BD

9. SYP. ASCORYL-LS 10ml PO TID

10. NEB. IPRAVENT 6th hourly 

NEB. BUDECORT 12th hourly

11. BP/PR/TEMP monitoring 4th hourly 

12. GRBS charting 12th hourly.

13. Intermittent CPAP if not maintaining on O2 

14. Syp. LACTULOSE 10 ml PO TID

A 70 YEAR OLD FEMALE PATIENT

A 70-year-old female Patient came to the OPD with the complains of SOB since 15 days aggravated since yesterday 

Complains of tingling sensation all over the body since 15 days

History of present illness:

Patient was apparently a symptomatic four years back then in January 2018 she developed vomitings SOB chest discomfort went to hospital and diagnosed with CAD(LAD) and was referred to higher Centre -Angiogram was done and stent was placed 

She is on regular medication till two years 

After follow-up, she stopped taking medication and was only taking herbal medication for joint pains 

Two months back she had a similar episode and diagnosed with CAD(RCA) -Angiogram was done, revealed triple vessel disease 

Since 15 days patient had SOB associated with tingling sensation all over the body

 no chest pain 

 no palpitations

 no Pedal Oedema 

Past illness:

 known case of CAD S/P PTCA

No DM/HTN

Personal history:

married Home maker by occupation appetite normal regular bowl and bladder moment no allergies no addictions

No significant family history

General examination :

patient is C/C/C

Pallor

vitals: 

temperature : 97.5°F

Pulse rate : 60 BPM 

Respiratory rate : 18 CPM

BP : 100/70 MMHG 

SPO2 : 98 @ RA

CVS: S1 S2 +

Respiratory system : NVBS+

P/A- soft non-tender

CNS - NO FND

Provisional diagnosis 

k/c/o CAD TVD (post PTCA) 

severe LV dysfunction with ?Cardio-renal syndrome type II

INVESTIGATIONS:

Hb: 8.8

Tlc: 8400

Plt.count: 2.34

CUE:

alb +

Pc: 3 to 4

Ec: 2 to 3

LFT:

TB: 0.96

DB: 0.20

AST: 17

ALP: 132 

ALB: 1.31 

RFT: 

Urea: 71

Creatinine: 2.6

UA: 10.2

Na+ : 146

K+ : 3.1

Cl- : 96

ABG:

PH: 7.55

PCO2: 28.6

PO2 : 72.4

HCO3- : 25.1

ST. HCO3- : 27.4 

SO2 : 94.3

ECG

Plan of Treatment : 

Fluid Restriction 1 L per day

Salt restriction less than 2.4 g per day 

Injection Lasix 40 mg/IV/BD

T. ECOSPORIN-Gold 75/40 MG/PO/HS

T.CARDIVAS 3.125 mg/PO/OD

T.PAN 40 MG/PO/OD (BBF)

T. B-COMPLEX PO/OD 

Strict I/O charting

Monitor vitals hourly

A CASE OF 80 YEAR OLD MALE PATIENT

A 80 year old male brought to casuality with c/o constipation since 20 days (on and off).

Not passing stools and Flatus since 5 days 

Shortness of breath since 5 days.

History of presneting illness:

Patient was apparently asymptomatic 3 years back and then he developed pain abdomen in epigastrium localized and not a/w nausea or vomitings aggravated after food intake.

Since 1 year patient complains that he used to wake up in the middle of night and felt breathless for a while. Since 20 days patient history of generalised weakness with loss of appetite and has constipation with small quantity of hard stools. Sinec 5 days patient complains he didn't pass stools and flatus which makes him discomfort associated with pain abdomen.

Personal history:

Patient lost his appetite since 20 days and disturbed sleep.

Addictions: H/o Smoking (Sutta) since 55 years. chronic alcoholic drinks 90ml whiskey daily.

General examination:

Patient consious, coherent, cooperative.

No signs of icterus, clubbing, lymphadenopathy, edema

Signs of pallor.

Vitals: 

Temp: afebrile

Pr: 90 bpm

Rr: 20 cpm

Bp: 130/80 mmhg

Spo2: 98%

Grbs- 132 mg/dl

Systematic examination:

CVS: S1 and S2 heard

RS: BAE + 

CNS: NAD

P/A: soft , tender.

Fever chart.

Diagnosis:

Constipation 2to ?Uremic gastroparesis with RCA territory Akinesia (?old MI).

Investigations on 10/12/21:

Hemogram:

Hb- 11.5

Tlc- 29,300

Plt count- 1.62

RFT:

Urea- 202

Creatinine- 5.9

Na+- 137

K+- 4.5 

Cl-- 90

LFT:

ALP- 437

ALB- 2.8

CUE:

ALB +

RBC - Absent.

ABG:

Ph- 7.473

Pco2- 23.9

So2- 95.6

cHCO3 (P.ST)c- 20.8

cHCO3(p)c- 17.3

Serology- negative.

USG Abdomen

 Chest Xray PA VIEW

xray erect abdomen

ECG

Investigations on 11/12/21

Hb: 11.7

Tlc: 33,450

Plt count: 2.31

Urea: 204

Na+ : 139

K+ : 4.1

Cl- : 96

Spot urine protein: 1.2

Spot urine Creatinine: 100.6

Spot urine Albumin: 0.11

CUE:

Albumin:  +

No sugars 

Ec: 2 to 4

Pc: 2 to 4

Investigations on 12/12/21

Hb: 10.9

Tlc: 22,700

Plt count: 1.59

Blood urea: 203

Serum creatinine: 3.4

Na+ : 144

Cl- : 98

K+ : 3.3

Treatment 

1. Ivf NS/RL/DNS continuous at 100ml/hr

2. Inj. PAN 40mg IV BD 

3. inj. ZOFER 4mg IV/SOS

4. Syp. LACTULOSE 20 ml PO/BD

5. Tab.ECOSPORIN 75 mg PO/OD

6. Tab.CLOPITAB 75 mg PO/OD

7. Tab. ATROVAS 10 mg PO/OD

8. Proctoclysis enema twice daily

9. BP/PR/TEMP monitoring 4th hourly.

50 year old female with pain abdomen

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50 year old female with pain abdomen a/w SOB Since 3 days and constipation since 2 days.

A 50 year old female patient came on 30/11/21 with c/o pain abdomen since 3 days a/w sob, constipation since 2 days.

H/o pain abdomen 2 months back

Hopi:

Patient was apparently asymptomatic 3 days back then she developed pain abdomen in right hypochondrium a/w sob grade 2 and 3

H/o nausea and vomiting 4 episodes 3 days back, no palpitations

History of past illness:

N/k/c/o htn/dm

H/o renal caliculi since 2 years managed conservatively.

Examination:

Patient was c/c/c

Temperature: afebrile

PR- 68/min

RR-26min

BP-130/70mmhg 

CVS:s1s2+

R.S:bae +

P/A: Soft, non tender,bs+

Probable diagnosis:

Constipation secondary to Paralytic ileus.

Treatment:

1.IVF- 45% NS @ 75ml/hr

2.Syp. DUPHALAC 10 ml PO BD

3.Tab. BUSCOPAN PO SOS

4.Tab. PAN 40 mg PO OD

5.Soap water enema

6.Monitor vitals 

7.Inform SOS

70 year old female patient

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 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 patient's 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 the comment box is welcome.

Unit 5 admission 

A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +

Dry cough since 1 year 

H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided

C/o burning micturition since 2 days 

C/o polyuria since 2 days

C/o biomass exposure since child hood daily

H/o on and off SoB since 10 to 15 years,using RMP medication 

HISTORY OF PAST ILLNESS:

No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures 

Not a k/c/oDM,HTN,CAD,CVA,TB

PERSONAL HISTORY:

Occupation:  house wife

Appetite: lost

Diet: Mixed 

Bowel and bladder movements:  Regular

Allergies: None

Habits: None 

FAMILY HISTORY: 

Not significant.

GENERAL EXAMINATION:

Patient is consious, coherent, cooperative 

Vitals:

Temperature : afebrile

RR: 14 cpm 

Bp:  120/80

HR: 105 bpm

Spo2: 100

GRBS: 131 mg%

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

SYSTEMIC EXAMINATION:

RS: BAE+, Diffuse Wheeze, crepts +

CVS: s1 and s2 heard

P/A: soft, non tender.

CNS: NAD

INVESTIGATIONS:

CBP:

HB:12.3

TLC: 10300

PL: 2.71

CUE:

Albumin and sugars: nil

EC:

PC: 

LFT:

TB: 0.83

DB: 0.20

ALB: 3.8

ALT:  25

ALP: 202

AST: 50

RFT:

UREA: 21

SR. CR: 0.8

UA: 2.0

Na: 141

K: 3.6

Cl: 91

Serology: negative 

ABG:

Ph: 7.443

Pco2: 37.4

Po2: 79.9

So2: 94.5

Hco3(p.st): 25.9

Hco3 pc: 25.2

XRAY:

A 70 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 patient's 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 the comment box is welcome.

Unit 5 admission 

A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +

Dry cough since 1 year 

H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided

C/o burning micturition since 2 days 

C/o polyuria since 2 days

C/o biomass exposure since child hood daily

H/o on and off SoB since 10 to 15 years,using RMP medication 

HISTORY OF PAST ILLNESS:

No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures 

Not a k/c/oDM,HTN,CAD,CVA,TB

PERSONAL HISTORY:

Occupation:  house wife

Appetite: lost

Diet: Mixed 

Bowel and bladder movements:  Regular

Allergies: None

Habits: None 

FAMILY HISTORY: 

Not significant.

GENERAL EXAMINATION:

Patient is consious, coherent, cooperative 

Vitals:

Temperature : afebrile

RR: 14 cpm 

Bp:  120/80

HR: 105 bpm

Spo2: 100

GRBS: 131 mg%

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

SYSTEMIC EXAMINATION:

RS: BAE+, Diffuse Wheeze, crepts +

CVS: s1 and s2 heard

P/A: soft, non tender.

CNS: NAD

INVESTIGATIONS:

CBP:

HB:12.3

TLC: 10300

PL: 2.71

CUE:

Albumin and sugars: nil

EC:

PC: 

LFT:

TB: 0.83

DB: 0.20

ALB: 3.8

ALT:  25

ALP: 202

AST: 50

RFT:

UREA: 21

SR. CR: 0.8

UA: 2.0

Na: 141

K: 3.6

Cl: 91

Serology: negative 

ABG:

Ph: 7.443

Pco2: 37.4

Po2: 79.9

So2: 94.5

Hco3(p.st): 25.9

Hco3 pc: 25.2

PROVISIONAL DIAGNOSIS:

Excarcerbation of COPD

? Viral pneumonia