GENERAL MEDICINE CASE PRESENTATION

A.S.SIVARAM

Roll no:- 07

3rd semester 

This is 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 patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio.

Case scenario 

A 49 yr old female patient came to opd with the chief complaints of Shortness of breath(SOB) -grade IV and worsening 

History of present illness


•SOB -5 to 6 months
On exertion
•Pedal edema and facial puffiness since 5 to 6 months
•Red urine output
•Fever -10 days -subside on medication-intermittent and low grade
•cough with sputum since 10 days

History of past illness

•k/c/o Hypertension-1 yr

Treatment History 

Hypertension Treatment since 1 yr
•Temla 40  mg tab

Personal History 

•non vegetarian 

Family history 

●No notable family history 

Physical examination 

No- pallor/Icterus/cyanosis/clubbing//malnutrition/lymphadenopathy/
Mild dehydration
Edema is seen

๐•๐ข๐ญ๐š๐ฅ๐ฌ
30/09/21
• ๐“๐ž๐ฆ๐ฉ๐ž๐ซ๐š๐ญ๐ฎ๐ซ๐ž-99°๐…
• ๐๐ฎ๐ฅ๐ฌ๐ž ๐ซ๐š๐ญ๐ž- 112/๐ฆ๐ข๐ง
• ๐‘๐ž๐ฌ๐ฉ๐ข๐ซ๐š๐ญ๐ข๐จ๐ง ๐ซ๐š๐ญ๐ž -28/๐ฆ๐ข๐ง
• ๐๐ฅ๐จ๐จ๐ ๐ฉ๐ซ๐ž๐ฌ๐ฌ๐ฎ๐ซ๐ž-170/110๐ฆ๐ฆ๐‡๐ 
• ๐’๐ ๐Ž2%-  82%
• ๐†๐‘๐๐’-187๐ฆ๐ 

1/10/21
• BP-140/90mmHg
• PR-78/min
• SP O2%-94-96% on BiPAP
• GRBS-132mg/dl

2/10/21

• BP- 130/90mmHg
• Temperature -98.6°F -Afebrile
• PR-100/min
• GRBS-187mg/dl

3/10/21
• BP -200/100mmhg
• PR-140bpm
• SP O2%-82%
• Temperature-101°F
• Respiratory rate-40/min



04/10/21
• Temprature-afebrile
• BP-130/80mmHg
• PR-102bpm

•SYSTEMIC EXAMINATION

CVS

No Thrills

*Cardiac Sounds - S1, S2 +

*No cardiac murmurs

RESPIRATORY SYSTEM     

*Dyspnoea - yes

*Yes Wheezing

*Position of Trachea - Central

*Vesicular sounds 

*adventious sounds are present 


ABDOMEN   

*Shape - scaphoid

*No tenderness, palpable mass, No free fluid, No bruits 

*Yes bowel sounds

*Hernial Orifices - Normal

*Liver, Spleen - Not palpable


CENTRAL NERVOUS SYSTEM         

*Level of consciousness - conscious

*Speech - Normal

*No signs of Meningeal Irritation

*Cranial nerves - Normal

*No motor or sensory deficit

INVESTIGATIONS

2๐‘ซ ๐‘ฌ๐’„๐’‰๐’ ๐’“๐’†๐’‘๐’๐’“๐’•
• LAD territory akinetic with RCA hypokinesia
• Moderate to severe LV Dysfunction
• Mild tricuspid regurgitation with mild pulmonary artery hypertension
• Sclerotic AV
• Transient LV dilated size-5.3cm
• Diastolic dysfunction
• No Pulmonary embolism /LV clot

ECG


Report









Provisional diagnosis

๐‡๐…๐ซ๐„๐… 2° ๐ญ๐จ   ๐‚๐€๐ƒ (๐„๐…-35%)
  CKD ( 4th stage)
With ? Cardiogenic pulmonary edema (resolved)

๐“๐ซ๐ž๐š๐ญ๐ฆ๐ž๐ง๐ญ

30/09/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin  and budecort  -8th hourl
• Inj.lasix 80mg i.v stat
• Inj.Nitroglycerin 1mg in 1ml i.v stat
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• Foleys catheterization

01/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin  and budecort  -8th hourly
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
•  Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm

02/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin 
•               budecort  -8th hourly
• Inj.lasix 40mg i.v BD
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Tab.Met-XL 50mg PO OD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm
• Salt restriction <2.4g/day
• Water restriction 2.1L /day

03/10/21

• Dialysis
• O2 inhalation  @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
•  Tab.Ecosprin (75/20mg) PO
• Tab.Amlong 10mg PO OD-8pm
• GRBS 8th hourly

04/10/21
• O2 inhalation  @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Nebulization with duolin 
•               budecort  -8th hourly
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Ecosprin AV (75 /25mg) PO
• Tab.Nicardia PO BD
• Tab.Arkamin 0.1mg PO /TID
• Salt restriction <2.4g/day
• Water restriction 2.1L /day

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