General medicine

SRINAINI 

Roll no:- 33

3rd semester 

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𝑪𝒂𝒔𝒆 𝒊𝒏 𝒃𝒓𝒊𝒆𝒇-

A 49yr old female who is a municipality worker  by occupation , was brought to casuality with complaints breathlessness and fever.

#𝑻𝒉𝒊𝒔 𝒊𝒔 𝒂𝒏 𝒐𝒏𝒈𝒐𝒊𝒏𝒈 𝒄𝒂𝒔𝒆 𝒂𝒏𝒅 𝒘𝒊𝒍𝒍 𝒃𝒆 𝒖𝒑𝒅𝒂𝒕𝒆𝒅 .

𝑫𝒂𝒕𝒆 𝒐𝒇 𝒂𝒅𝒎𝒊𝒔𝒔𝒊𝒐𝒏-30/09/21
𝐂𝐡𝐢𝐞𝐟 𝐂𝐨𝐦𝐩𝐥𝐚𝐢𝐧𝐭𝐬
• SOB since 2-3days, Grade 4,Worsening
• Fever since 10days ,intermittent type ,low grade and subsides with medication.
• Pedal oedema since 6months
• Facial puffiness since 5-6months
• Reduced urine output

𝐇𝐢𝐬𝐭𝐨𝐫𝐲 𝐨𝐟 𝐩𝐫𝐞𝐬𝐞𝐧𝐭 𝐢𝐥𝐥𝐧𝐞𝐬𝐬
• C/O of cough associated with sputum,scanty since 10days
• H/o Covid vaccination 8days ago

𝐇𝐢𝐬𝐭𝐨𝐫𝐲 𝐨𝐟 𝐩𝐚𝐬𝐭 𝐢𝐥𝐥𝐧𝐞𝐬𝐬
• K/c/o  Hypertension since 1yr
• Not a k/c/o of diabetes mellitus

𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
She has been treated for hypertension :-
Tab.TELMA 40mg- irregular medication

𝐏𝐞𝐫𝐬𝐨𝐧𝐚𝐥 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
• Married
• Appetite is reduced
• Non vegetarian
• Urine outpit decreased

𝐅𝐚𝐦𝐢𝐥𝐲 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
• 𝑵𝒐 𝒇𝒂𝒎𝒊𝒍𝒚 𝒉𝒊𝒔𝒕𝒐𝒓𝒚 𝒐𝒇 𝒅𝒊𝒂𝒃𝒆𝒕𝒆𝒔,𝒉𝒚𝒑𝒆𝒓𝒕𝒆𝒏𝒔𝒊𝒐𝒏 ,𝒔𝒕𝒓𝒐𝒌𝒆,𝒉𝒆𝒂𝒓𝒕 𝒅𝒊𝒔𝒆𝒂𝒔𝒆 ,𝒂𝒔𝒕𝒉𝒎𝒂 ,𝒕𝒖𝒃𝒆𝒓𝒄𝒖𝒍𝒐𝒔𝒊𝒔 ,𝒉𝒆𝒂𝒓𝒕 𝒅𝒊𝒔𝒆𝒂𝒔𝒆𝒔, 𝒐𝒓 𝒄𝒂𝒏𝒄𝒆𝒓𝒔.

𝐆𝐞𝐧𝐞𝐫𝐚𝐥 𝐞𝐱𝐚𝐦𝐢𝐧𝐚𝐭𝐢𝐨𝐧

• Well nourished and moderately built
• No pallor
• No cyanosis
• No icterus
• No lymphadenopathy
• Pedal edema
• Mild dehydration

𝑺𝒚𝒕𝒆𝒎𝒊𝒄 𝒆𝒙𝒂𝒎𝒊𝒏𝒂𝒕𝒊𝒐𝒏

𝑪𝑽𝑺
• No murmurs
• No thrills
• S1,S2 heard

𝑹𝒆𝒔𝒑𝒊𝒓𝒂𝒕𝒐𝒓𝒚 𝒔𝒚𝒔𝒕𝒆𝒎
• No dyspnoea
• Wheezing present
• Trachea is centrally placed
• Vesicular breath sounds
• Adventitous sounds -rales 1  rub

𝑨𝒃𝒅𝒐𝒎𝒆𝒏 𝒔𝒚𝒔𝒕𝒆𝒎
• No tenderness
• No palpable mass
• Scaphoid shaped abdomen
• No free fluid
• Liver and spleen are not palpable

𝑪𝑵𝑺
• Concious
• Normal speech
• No signs of meningeal irritation
• Normal sensory and motor system
𝐕𝐢𝐭𝐚𝐥𝐬
30/09/21
• 𝐓𝐞𝐦𝐩𝐞𝐫𝐚𝐭𝐮𝐫𝐞-99°𝐅
• 𝐏𝐮𝐥𝐬𝐞 𝐫𝐚𝐭𝐞- 112/𝐦𝐢𝐧
• 𝐑𝐞𝐬𝐩𝐢𝐫𝐚𝐭𝐢𝐨𝐧 𝐫𝐚𝐭𝐞 -28/𝐦𝐢𝐧
• 𝐁𝐥𝐨𝐨𝐝 𝐩𝐫𝐞𝐬𝐬𝐮𝐫𝐞-170/110𝐦𝐦𝐇𝐠
• 𝐒𝐏 𝐎2%-  82%
• 𝐆𝐑𝐁𝐒-187𝐦𝐠

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
•

𝐈𝐧𝐯𝐞𝐬𝐭𝐢𝐠𝐚𝐭𝐢𝐨𝐧𝐬
2𝑫 𝑬𝒄𝒉𝒐 𝒓𝒆𝒑𝒐𝒓𝒕
• 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

30/9/21

Hemogram

ABG

3/10/21

𝑻𝒆𝒎𝒑𝒆𝒓𝒂𝒕𝒖𝒓𝒆 𝒄𝒉𝒂𝒓𝒕𝒊𝒏𝒈

𝐏𝐫𝐨𝐛𝐚𝐛𝐥𝐞 𝐝𝐢𝐚𝐠𝐧𝐨𝐬𝐢𝐬
𝐇𝐅𝐫𝐄𝐅 2° 𝐭𝐨   𝐂𝐀𝐃 (𝐄𝐅-35%)
  CKD ( 4th stage)
With ? Cardiogenic pulmonary edema (resolved)

𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭

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