58 YEAR OLD FEMALE WITH SHORTNESS OF BREATH AND PEDAL EDEMA



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-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've 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 a diagnosis and treatment plan.

CHIEF COMPLAINTS:

C/O fever since 15 days
C/O shortness of breath since 3 days.
C/O B/L Pedal edema since 3 days

History of present illness:

Patient was apparently asymptomatic 15 days back then  she developed 
• Fever,high grade on and off ( intermittent), associated with chills. Relieved on taking medication.
No H/O FEVER, RETRO ORBITAL PAIN.
•SHORTNESS OF BREATH  since 3 days( grade 3-4)
Orthopnea+
NO PND.
PEDAL EDEMA since 3 days which is pitting type.
No H/O Vomiting, diarrhoea,headache.

PAST HISTORY:

Not a K/C/O HTN, DM,TB,CVA,CAD, EPILEPSY,ASTHAMA.

H/O FALL 3 days back ( due to giddiness) and loss of consciousness for short period and woke up on her own 3 days back.

FAMILY HISTORY:

No similar complaints in the family.

Personal history:

Diet- mixed

Appetite- decreased  since 4-5 days.

Bowel and bladder movements- Regular

 Addictions - occasional

GENERAL EXAMINATION:




Pt is conscious, coherent and cooperative 

No pallor, no icterus, no Cyanosis, no clubbing, no lymphadenopathy

VITALS- day 1

TEMP-98.6 F

BP-120/80 MM HG

PR- 92 bpm

RR-16/min

Spo2- 93% with 6  litre  of oxygen 

GRBS- 110 mg/dl

Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:   Soft,  tenderness in right iliac fossa,right hypochondrium, epigastric region, no organo megaly.

 AUSCULTATION:

BOWEL SOUNDS HEARD

RESPIRATORY SYSTEM:

B/L AIR ENTRY+

DECREASES BREATH SOUNDS IN RIGHT AND LEFT ISA,  CREPTS PRESENT IN RIGHT INFRA AXILLARY AREA.


CARDIOVASCULAR SYSTEM:

S1S2+

CNS:

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.


Investigations:





PROVISIONAL DIAGNOSIS:

ACUTE FEBRILE ILLNESS WITH B/L PLEURAL EFFUSION.

TREATMENT:

1.Oxygen inhalation to maintain SPO2 ABOVE 90

2. INJ PIPTAZ 2.25 gm /IV/BD

3.INJ LASIX 40mg /IV/BD

4. INJ TRAMADOL 1amp in 100ml NS /IV/ SOS 

5.TAB DOLO 650mg PO/SOS

6. TEMPERATURE CHARTING 6th hourly 

7.ZYTEE GEL FOR LOCAL APPLICATION 



26/10/22

58/F

S- shortness of breath decreased.


O- Patient is conscious coherent and cooperative

BP- 110/60mm hg

PR- 82bpm

RR- 24cpm

TEMP-98.6F @ 8 am

SpO2- 96% on RA

CVS-S1S2+ 

R/S-BLAE+,left INFRA AXILLARY AREA CREPTS+, ISA+

P/A-soft , non tender

CNS-NFND.


A- PULMONARY ARTERY HYPERTENSION

WITH B/L PLEURAL EFFUSION WITH AKI


P-

1.INJ PIPTAZ 2.25 gm/IV/TID

2. INJ LASIX 40 mg/IV/BD

3.IVF NS @75 ml/hr IV INFUSION

4.INJ OPTINEURON 1amp in 100 ml NS/IV/OD

5.INJ PAN  40 MG IV/OD.


27/10/22

58/F

S- shortness of breath decreased

O- Patient is conscious coherent and cooperative

BP- 110/60mm hg

PR- 69bpm

RR- 24cpm


CVS-S1S2+ 

R/S-BLAE+

P/A-soft , non tender

CNS-NFND.


TEMP-98.6F @ 8 am

SpO2- 94% on RA


Input-Output

-2500ml/2100ml


A- PULMONARY ARTERY HYPERTENSION

WITH B/L PLEURAL EFFUSION WITH AKI (PRE RENAL RESOLVED)


P



1. INJ LASIX 40 mg/IV/BD

2.IVF NS @75 ml/hr IV INFUSION




PLEURAL FLUID ANALYSIS

CELLS-600

NEUTROPHILS PREDOMINANT

PLEURAL PROTEIN-3.2

SERUM PROTEIN-5.6

PLEURAL LDH-234

SERUM LDH-268

ANALYSIS

PLEURAL FLUID ANALYSIS -? EXUDATE















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