35YEAR OLD MALE WITH SOB

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-centered online learning portfolio and your valuable inputs on the comment box.

CHIEF COMPLAINTS

A 35 year old male who is daily wage worker came with chief complaints of shortness of  breath and fever since 1 week. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 week back, then he developed 
• shortness of breath on exertion, since 1 week.
• high-grade fever since 1 week, more during night, relieved on medication and relapses back.
• decreased urine output since 1 week
• dragging type of pain in both legs and hands, associated with generalised weakness.
• No food intake since 1 week
• orthopnea and PND present since 4 days

HISTORY OF PAST ILLNESS

No history of DM, HTN, TB, Epilepsy, leprosy, CAD, CVN, Asthma or any other chronic illness.
No history of previous transfusion. 

PERSONAL HISTORY

Built : Weakly nourished
Appetite : Decreased since 1 week
Diet : mixed
Sleep : Decreased since 1 week 
Bladder movements: 
Anuria since 1 day associated with burning micturition.
Bowel movements: regular
Addictions : toddy consumer in summer season.
Regular alcohol consumer, once a week.
No h/o smoking

FAMILY HISTORY



His wife was diagnosed with pulmonary TB, got admitted in hospital 1 month ago. 

GENERAL EXAMINATION

Patient was coherent, cooperative and conscious. Well orientated to time and space.
Pallor : absent
Icterus : absent
Clubbing: absent
Cyanosis : absent
Koilynochia: absent
Pedal edema : absent
Lymphadenopathy: absent.






Vitals:
Temperature:


Blood pressure:110/70mmhg
Respiratory rate:16cpm
Pulse rate:110bpm
SYSTEMIC EXAMINATION 

Respiratory system

Inspection 
Shape and symmetry of chest : normal, symmetrical 
Trachea : central
Respiratory movements: normal
Apical impulse: seen
Skin over the chest : normal
Dysnea : present

Palpation
Trachea : central
Respiratory movements: normal
Fremitus : normal

Percussion
Normal 
Auscultation
Breath sounds: vesicular
Adventitious sounds : absent 
Vocal resonance: normal on both sides

Other systems

CNS : No facial asymmetry, all reflexes are normal.
GIT : Tenderness present in hypochondrium, umblical and right lumbar region.
Liver and sleep not palpable.
Mild ascites.
CVS : Thrills , present
S1, S2 heard
No murmers.
Raised JVP. 

INVESTIGATION:
















CHEST X RAY

ABDOMINAL X RAY

ECG FINDINGS: 

Biphasic T waves in V1 - V4
T wave inverted in II, III, avf. 
2D echo findings:
-D shaped LV
-Severe TR+ with PAH
-Trivial MR+/AR+
-No AS/MS
-EF=60, RSVP=80mmHg
-No diastolic dysfunction
-Minimal PF+
-Dilated RA,RV,IVC
-IVC size(2.0cm)-non collapsing

USG FINDINGS:



PROVISIONAL DIAGNOSIS:
Right heart failure 
-Severe pulmonary artery hypertension, 
-Type1 respiratory failure(Resolved)    
 -Edematous bowel loops,
 -Prerenal AKI, 
-Severe metabolic acidosis 2° to sepsis ? 
- Acute hepatitis

TREATMENT:
1)O2 inhalation, increase or decrease according to requirement, spo2>/=92%
2)Neb with DUOLIN 6th hourly
3)INJ.PIPTAZ 2.25gm IV/TID
4)INJ.LASIX 40mg IV/BD
5)IVF NS/RL @50ml/hr/IV
6)INJ.PAN 40mg IV/OD
7)INJ.THIAMINE 200mg in 100ml NS/IV/BD
8)INJ.OPTINEURON in 100ml NS/IV/OD over 30min
9)T.DOM 10mg PO/BD
10)VITALS MONITORING 4TH HOURLY
11) TEMPERATURE MONITORING 4TH HOURLY
12) STRICT I/O MONITORING

Comments

Post a Comment

Popular posts from this blog

A 70YRS OLD FEMALE WITH BREATHLESSNESS

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of i
Read more

54year old male with altered state and hiccups

Image
 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-centered online learning portfolio and your valuable inputs on the comment box. CHIEF COMPLAINTS: 27/10/22: A 54 year old male presented to casualty in altered state with hiccups since 5days, uprolling of eyeball and frothing since morning i.e., on 27th oct (day of admission). HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 22yrs back after which he started consuming tobacco in the form of chewing ghutka. Initially he used to consume 1packet/day which gradually progressed to 8packets everyday currently. Patient is currently in drowsy state,h
Read more

A 75 year old woman came with chief complaints of Involuntary movement of hands and head

Image
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-centered online learning portfolio and your valuable inputs on the comment box. A 75 year old woman came with chief complaints of  Involuntary movement of hands and head bobbing since 7AM 22/2/22 Burning micturition since 1 week  History of presenting illness:  Patient was apparently asymptomatic 10 days back and then developed fever which was insidious in onset, continuous and subsided with medication.  Involuntary movement of hands and bobbing of head at frequent intervals seen.  Frequent episodes of burning micturition which subsided on medication present.
Read more