44 year old 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.



A 44 year old male patient it came to casualty with 
C/o shortness of breath (grade II) 
C/o B/L PEDAL EDEMA ( pitting type ) since 1 week 
C/o decreased URINE OUTPUT since 1 week
C/o FACIAL PUFFINESS since 1 week 
HOPI-Pt was apparently asymptomatic 1 week back then developed fever associated with chills and rigor, was diagnosed with typhoid and was treated outside in a private hospital 
Pt also C/o loss of appetite, and 2 episodes of vomiting ( non bilious , non projectile ) not A/W nausea.
Pt is a K/C/O 
-CKD since 10 years on regular medication 
- DM since 4-5 years 
(on GLIMI M2 and GLIMI M1)
-HTN since 1 year - on Tab TELMA-A

PERSONAL HISTORY-
Appetite -normal
Vegetarian
Bowel and bladder - regular
Non alcoholic
FAMILY HISTORY-
No history of diabetes, hypertension,heart disease,Cancers.
GENERAL EXAMINATION-
Patient was examined in a well lit room, after taking informed consent.
Conscious, coherent, cooperative,well nourished,well oriented to time,place, person.
Vitals:
TEMP+98.4°F
BP-130/80MMHG
PR-89 BPM
RR- 20CPM
SPO2-98% @ RA
SYSTEMIC EXAMINATION:
CVS-
S1 and S2 HEARD 
NO MURMUR
APEX BEAT- 6TH ICS LATERAL AND OUTWARD
JVP-RAISED , EPIGASTRIC PULSATIONS PRESENT 
RESPIRATORY SYSTEM:-
NVBS + NO CRYPTS
P/A-SOFT, NON TENDER
CNS-
HMF INTACT
WT-83 KG


INVESTIGATIONS:

PROVISIONAL DIAGNOSIS-
HEART FAILURE with PRESERVES EJECTION FRACTION with EF -55% WITHCKD SINCE 10 YEARS STAGE -IIIB with DM since 5 YEARS with HTN since 1 YEAR

TREATMENT-
SALT RESTRICTION < 2.4 GM/DAY
FLUID RESTRICTION< 1 LT/DAY
INJ LASIX 40MG /IV/BD ( IF BP>110MHG)
INJ PANTOP 40 MG /IV/OD
TAB. NODOSIS 550 MG /PO/OD
TAB. SHELCAL 500MG /PO/OD
TAB PCM 500MG /PO/SOS
INJ. PIPTAZ 2.25 G/IV/BD(DAY 1)
INJ. NEOMOL 100 ML /IV/SOS
MONITOR VITALS HOURLY
STRICT I/O CHARTING
INJ HAI PRE MEAL S/C 8AM-2PM-8PM
GRBS MONITORING

Popular posts from this blog

General medicine assignment May 2021

 Online blended monthly assignment toward summative assessment for the month of May 2021 Name: V.Sai Jaya Krishna Roll no: 137 Batch: 2017 Semester: 8TH SEMESTER I have been given the following cases 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 diagnosis and come up with a treatment plan. This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases. Pulmonology A.Link: https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html 1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology...
Read more

A 46 year old Female with Acute kidney injury

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking her 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 cocllective current best evidence based inputs. This E log book reflects my patient-centered online learning portfolio and your inputs on the comment box is welcomed. V.Sai jaya krishna, 9th sem, Roll no-137. 46 YEAR old female a resident of Rangareddy distri ct and a agriculture labour by occupation was transferred to the general medicine OPD with Chief complaints:  Lower back pain (at hip joint) since 10 years. History of presenting illness: Patient was apparently asymptomatic 10 years back then she developed bilateral hip joint pain and difficulty in walking without support.  The pain was insidious in onset, gradually progressive.  Aggrevating factors are wal...
Read more