85 year old female with shortness of breath, fever, cough
85 year old female with shortness of breath, fever, cough
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 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 inputs on the 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
85 F presented to the casualty with chief complaints of
Shortness of breath, since 1 week
cough and fever since 1 week
HOPI:
Patient was farmer by occupation used to go to fields by 7-8am and engage herself in planting and harvesting crops and return back home by evening, but from last 15 years her son’s have started taking care of her and her land post which she’s staying home doing regular home chores. Patient was apparently asymptomatic five months back then was diagnosed with hypertension and was on T AMLONG 5mg SHE WAS EXPERIENCING SHORTNESS OF BREATH SINCE 4 MONTHS WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE FROM GRADE 2 TO GRADE 4
2MONTHS BACK SHE WENT TO LOCAL HOSPITAL WITH C/O CHEST PAIN AND BREATHLESSNESS (GRADE 3) WAS DIAGNOSED WITH ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND WAS STARTED ON T.DIGOXIN ,T .DILTIAZEM ,T.DABIGATRAN ,
T.DYTOR PLUS WHICH SHE USED FOR 15 DAYS AND STOPPED THEM ABRUPTLY .
SINCE 1 WEEK PATIENT HAS HIGH GRADE
FEVER INTERMITTENT TYPE RELIEVED PARTIALLY ON MEDICATION NOT ASSOCIATED WITH CHILLS AND RIGORS
H/O PRODUCTIVE COUGH SINCE A WEEK WITH MUCOID NON FOWL SMELLING AND NON BLOOD TINGED SPUTUM
PERSONAL HISTORY:
Decreased appetite takes mixed diet, regular bowel habits , normal micturition , no allergies
GENERAL PHYSICAL EXAMINATION
Patient conscious coherent cooperative
Moderately built and nourished
Pallor present
B/L pitting edema present till knee
Jvp raised
No, icterus, cyanosis, clubbing, lymphadenopathy
No, icterus, cyanosis, clubbing, lymphadenopathy
Vitals
Bp:130/90mmhg
RR-20cpm
PR-120bpm , irregular rhythm , normal volume, no radioradial delay
SPO2-75% at RA and 96% on 6lt of oxygen
TEMP-98.3F
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - slight deviation to right
Expansion of chest is symmetrical.
Auscultation:
B/L air entry present . Diffuse crepts heard in all lung fields
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - raised
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
PER ABDOMEN:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion - dull note heard over flanks
Auscultation- normal bowel sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Higher mental function - intact
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Provisional diagnosis:
? Community acquired pneumonia
Atrial fibrillation with fast ventricular rate
Investigations:
24/12/22
Fever chart
Investigations
On 25/12/22
On 26/12/2023
On 30/12/2022
ECG
ABG
2D ECHO
No RMWA , mild LVH, moderate MR, AR, TR ; EF =54%, IVC - 2.15 , dilated, noncollapsing,
Dilated RA, LA,RV, IVC
IVC POST LASIX
Earlier investigations done on (10/11/22)
CT CHEST -
FIBROTIC CHANGES IN RIGHT UPPER LOBE ,FIBROBRONCHIECTATIC CHANGES @ RIGHT MIDDLE LOBE (POST INFECTIOUS SEQUEL)
MILD CARDIOMEGALY
CT SCAN images showing aortic calcification and tracheal calcification
2D ECHO-
MAF+ , DILATED RA/LA, EF =50% , MODERATE TO SEVERE MR
SPIROMETERY-
FEV1/FVC=67.74 PREDICTED (36%)
PEFR - 39%
TREATMENT :
24/12/22:
INJ LASIX 40mg IV BD
INJ MONOCEF 1 Gm IV BD
TAB DOLO 650 mg PO/TID
TAB METXL 25mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
SYP ASCORIL -LS 10ml PO TID
CPAP
Vitals monitoring 4th hrly
25/12/22( DAY 2)
PATIENT PRESENTED TO THE OPD WITH C/O SOB SINCE 3-4 MONTHS, FEVER AND COUGH SINCE 7 DAYS
S
COUGH REDUCED
NO FEVER SPIKES
SOB REDUCED
C/O B/L LEG PAIN +
STOOLS NOT PASSED
O
Pt is on CPAP -PC
P support = 8cm H2O
FiO2 = 40%
PEEP = 7cm of H2O
Pt is C/C/C
BP:120/70mmHg
PR:71bpm
RR:19cpm
SpO2:100% on CPAP WITH FiO2 40%
Temp :afebrile
Grbs = 89mg/dl
CVS:S1S2 +
RS : BAE +, crepts + in right IMA AND IAA
Crepts+ in left IAA
no wheeze
PA-soft , no organomegaly, non tender
CNS - NAD
A
? Community acquired pneumonia
Atrial fibrillation with fast ventricular rate
Heart failure (RHF>LHF)
P
INJ LASIX 40mg IV BD
INJ CLEXANE 40MG IV OD
INJ MONOCEF 1 Gm IV BD
TAB DOLO 650 mg PO/TID
TAB METXL 25mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
SYP ASCORIL -LS 10ml PO TID
INTERMITTENT CPAP
Vitals monitoring 4th hrly
26/12/22( DAY 3)
GM unit 6
ICU BED 6
PATIENT PRESENTED TO THE OPD WITH C/O SOB SINCE 3-4 MONTHS, FEVER AND COUGH SINCE 7 DAYS
S
COUGH REDUCED
1 FEVER SPIKE @ 4:00 AM
STOOLS PASSED
O
Pt is on CPAP -PC
P support = 10cm H2O
FiO2 = 60%
PEEP = 6cm of H2O
Pt is C/C/C
BP:120/70mmHg
PR:74 bpm
RR:20cpm
SpO2:100% on CPAP WITH FiO2 60%
Temp :afebrile
CVS:S1S2 +
RS : BAE +, crepts + in right ICA, IMA, IAA
Crepts+ in left IMA, IAA
no wheeze
PA-soft , no organomegaly, non tender
CNS - NAD
A
? Community acquired pneumonia
Atrial fibrillation with fast ventricular rate with Heart failure (RHF>LHF) ? Old pulmo TB
P
INJ LASIX 40mg IV BD
INJ CLEXANE 40MG IV OD
INJ MONOCEF 1 Gm IV BD
TAB DOLO 650 mg PO/TID
TAB METXL 25mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
NEB MUCOMIST 8th HRLY
SYP ASCORIL -LS 10ml PO TID
INTERMITTENT CPAP
Vitals monitoring 4th hrly
http://ajayaddula.blogspot.com/2022/12/85-year-old-female-with-shortness-of.html
27/12/22( DAY 4)
GM unit 6
ICU BED 6
PATIENT PRESENTED TO THE OPD WITH C/O SOB SINCE 3-4 MONTHS, FEVER AND COUGH SINCE 7 DAYS
S
MILD COUGH
NO FEVER SPIKES
STOOLS PASSED
O
Pt is on INTERMITTENT CPAP -PC
P support = 10cm H2O
FiO2 = 50%
PEEP = 6cm of H2O
Pt is C/C/C
BP:130/80 mmhg
PR:84 bpm
RR:20cpm
SpO2:94% at RA
100% on intermittent CPAP WITH FiO2 50%
Temp :afebrile
CVS:S1S2 +
RS : BAE +, No crepts,
wheeze in right IMA
PA-soft , no organomegaly, non tender
CNS - NAD
A
? Community acquired pneumonia
Atrial fibrillation with fast ventricular rate with Heart failure (RHF>LHF) ? Old pulmo TB
Culture and sensitivity of blood , sputum, urine are negative.
P
INJ LASIX 40mg IV BD
INJ CLEXANE 40MG IV OD
INJ MONOCEF 1 Gm IV BD
TAB DOLO 650 mg PO/TID
TAB METXL 25mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
NEB MUCOMIST 8th HRLY
SYP ASCORIL -LS 10ml PO TID
INTERMITTENT CPAP
Vitals monitoring 4th hrly
29/12/22( DAY 6)
PATIENT PRESENTED TO THE OPD WITH C/O SOB SINCE 3-4 MONTHS, FEVER AND COUGH SINCE 7 DAYS
S
C/O COUGH
STOOLS PASSED
O
Pt is C/C/C
BP:110/70 mmhg
PR:84 bpm , irregularly irregular pulse
RR:20cpm
SpO2:97% at RA
Temp :afebrile
CVS:S1S2 +
RS : BAE + NVBS HEARD
PA-soft , no organomegaly, non tender
CNS - NAD
A
? COPD with Atrial fibrillation with fast ventricular rate with Heart failure (RHF>LHF) ? Old pulmo TB
Culture and sensitivity of blood , sputum, urine are negative.
CBNAAT REPORT IS NEGATIVE
P
INJ LASIX 40mg IV BD
INJ CLEXANE 40MG SC OD
INJ MONOCEF 1 Gm IV BD D6
TAB AZITHROMYCIN 500 mg PO/OD D1
TAB DOLO 650 mg PO/TID
TAB METXL 50mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
NEB MUCOMIST 8th HRLY
SYP GRILLINCTUS 10ml PO TID
TAB WARFARIN 5 MG PO/OD D2
Vitals monitoring 4th hrly
30/12/22( DAY 7)
GM unit 6
AMC CUBICLE BED
PATIENT PRESENTED TO THE OPD WITH C/O SOB SINCE 3-4 MONTHS, FEVER AND COUGH SINCE 7 DAYS
S
C/O COUGH
STOOLS PASSED
O
Pt is C/C/C
BP:110/70 mmhg
PR:82 bpm , irregularly irregular pulse
RR:20cpm
SpO2:98% at RA
Temp :afebrile
CVS:S1S2 +
RS : BAE + NVBS HEARD
PA-soft , no organomegaly, non tender
CNS - NAD
A
? COPD with Atrial fibrillation with fast ventricular rate with Heart failure (RHF>LHF) ? Old pulmo TB
P
TAB LASIX 40mg PO BD
INJ CLEXANE 40MG SC OD D6
INJ MONOCEF 1 Gm IV BD
TAB AZITHROMYCIN 500 mg PO/OD D2
TAB DOLO 650 mg PO/TID
TAB METXL 50mg PO/OD
NEB IPRAVENT 8th HRLY
NEB BUDECORT 12th HRLY
NEB MUCOMIST 8th HRLY
SYP GRILLINCTUS 10ml PO TID
TAB WARFARIN 5 MG PO/OD D3
Vitals monitoring 4th hrly
PLAN FOR DISCHARGE
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