A 57 years old Female with SOB
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I have 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 diagnosis and treatment plan
13/9/22
A 57 year old female came to the opd with chief complaints of
-Shortness of breath since 6days.
-decreased appetite since 5days.
History of presenting illness:
Patient was apparently asymptomatic 50 years back the she developed polio since then her lower limbs are deformed.
15 years back she had fever and decreased urine output for which she visited hospital and diagnosed with renal failure.since then she was on medication.And she is also diagnosed with Hypertension and managed on medication.
All the 50years she managed to do her own work and labour work but 2years back she fell down accidentally on her knees since then she started crawling.
1month back she had a fever and relived with medication again after 3days back she had fever and shortness of breath and no urine output for 6hrs then she visited RMP and took medication small quantities of urine passed but again had no urine output from night 8pm to morning 11:30am then foley’s was kept 50ml urine is passed but sob is not subsided then they referred to our hospital.
Past history:
N/K/C/O Diabetes,Asthma,Tuberculosis,Epilepsy.
Personal history:
Diet - mixed
Appetite - Decreased since 6 day
Sleep - Inadequate
Bowel -Regular
Bladder-irregular
Addiction -none
Allergies - None
Family history:
Her younger daughter had a history of polio and she expired.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative. Well oriented to time , place and person. Moderately built and nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema - B/L pedal edema , pitting type
VITALS : 13/9/22
Afebrile
PR - 92bpm Regular ; normal volume
RR - 21cpm
BP - 130/99mmHg
SpO2 - 90%
SYSTEMIC EXAMINATION
CVS : S1,S2 heard and NO Murmurs
RS :Normal vesicular breath sounds-Present
B/L Crepts-Present
PER ABDOMEN : Soft ; Non Tender ; Bowel sounds-Present.
CNS : Higher Mental functions-Intact , No focal Neurological deficits.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Acute pulmonary edema
NSAID induced nephropathy
Refractory metabolic acidosis
Refractory hyperkalemia
Chronic kidney Disease
Hypertension
TREATMENT
Head end elevated upto 30°
O2 supplement (if spo2 - >90%)
Inj Piptaz 2.25gm iv bd
Tab Lasix 40mg iv tid
Neb with Duolin and budecost-4th hourly
Tab Nicardia 10mg po bd
Tab Nodosis 500mg po tid
Tab Shelcal 500mg po tid
Tab Bio D3 po od( weekly over)
Tab Orofer-XT po od
VITALS : (14/9/22)
No presenting complaints
SOB reduced
Cough +
Temp : 98.6*F
BP : 130/70 mmHg
PR : 98bpm regular ; normal volume
CVS : s1 and s2 heard ; No murmurs
RS : Normal vesicular breath sounds ; B/L crepts +
Per abdomen : soft and non tender
Bowel sounds +
SpO2 : 98% @ 4lit of O2
GRBS : 133mg/dl
Investigations
TREATMENT :
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