58 year old male 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-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 SHORTNESS OF BREATH SINCE TODAY MORNING 3AM.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 years back.
Then he developed  right sided hemiplegia, for which he took medication and was also diagnosed to have type 2 diabetes mellitus and hypertension.
After 3 years he was operated for Hernia.
After 1 year, he had severe back pain, went to hospital, xray KUB was done and diagnosed to have renal calculi.
2 months back  he developed shortness of breath, came to our hospital and was diagnosed with AKI on CKD with emphysematous pyelonephritis underwent 3 sessions of hemodialysis.
Today morning  he developed shortness of breath,which was insidious in onset, gradually progressive.
Orthopnea+

HISTORY OF PAST ILLNESS

H/o DM , HYPERTENSION SINCE 5 YEARS

No history of  TB, Epilepsy, leprosy, CAD,  Asthma.

PERSONAL HISTORY:

Appetite :  decreased.

Diet : mixed

Sleep : adequate 

Bladder movements: normal

Bowel movements: regular

Addictions : consumes alcohol 2-3times/ week. Since

Last time consumed 1 week back.

 h/o smoking- 3 beedis/ day since

FAMILY HISTORY

No significant family history.

GENERAL EXAMINATION



Pallor : present.

Icterus : absent

Clubbing: absent

Cyanosis : absent.

Pedal edema : absent

Lymphadenopathy: absent.


O/E

PR-111/min
RR- 34/min
BP- 160/100 mmHg
Spo2- 67% at RA.
GRBS- 461 mg%

                             Day 1  12:20pm

                        Day 1 5:00pm

                           Day 1  6:50pm

Day 1 11:30pm

Day 2 5:00 am




Blood urea- 106

Serum creatinine -4.0

RBS -332 mg/dl.



Diagnosis:

- CARDIOGENIC PULMONARY EDEMA SECONDARY TO ANTERIOR WALL MI.
DM+,HTN+,CKD.

Treatment:

1. INJ PIPTAZ 2.25mg IV TID
2.INJ LASIX 40mg IV BD
3. INJ LEVIPIL 500mg IV BD
4. INJ HEPARIN 5000 U IV QID
5. T NICARDIA 10 mg PO TID
6.T OROFER XT PO OD
7. T NODOSIS 500mg IV BD
8. T SHELCAL XT PO OD.
9. T ECOSPIRIN AV PO HS




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