HELLO GUYS, 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 evidence based input
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 diagnosis and treatment plan.
UNIT 5 admission:
A 60 year old man presented at 9:10PM to casualty with c/o
- SOB since 4pm today
-cough since 4pm
Patient presented with c/0 sudden onset of dyspnea since 4pm today with productive cough since 4pm today.He was apparently asymptomatic 25years back after which he got diagnosed to be a diabetic . He was on irregular medications also gives h/0 LOC while going to washroom . Regular alcoholic since 10years -consumes 90-180ml whiskey/day.last alcoholic consumption was 5years back . Gutka consumption 10years back for 20years
5years back - B/L pedal Edema-diagnosed with CKD
2years back -SOB on supine position , relieved on sitting posture along with B/L pedal Edema.
1year back - SOB (grade 4). H/O CAD in January ?MI
February- presented to our casualty with SOB and was diagnosed with HFPEF and also k/c/o ckd(diagnosed 5years back when patient developed B/L pedal edema).
On 18/10/21- he came with SOB since 2 hours along with right sided chest pain since 2hrs.
Vitals at admission :
Temperature: a febrile
PR-86 bpm
RR-26cpm
BP-150/90 mmhg
Sp02- 92% at RA
GRBS- 151 mg%
General examination :
Pallor - PRESENT
Icterus,cyanosis,lymphadenopathy,clubbing,oedema of feet,dehydration- ABSENT
Systemic examination. :
CVS -
JVP - present
Apex beat -6th ics at mcl
S1s2 - heard
RS-
Inspiratory crepts in B/L IMA, IAA, ISA
DIAGNOSIS:
-HFPEF with CKD
-k/c/o type 2 DM since 25 years
-k/c/o HTN since 10 years
DAY 1:
SOAP NOTES :
ICU 2nd BED.
S: fever spike , SOB reduced.
O: pt is conscious , coherent , cooperative BP:100/80mmhg. Temp : 101F, PR:116 bpm , spo2:98%on 4L02. CVS: S1S2 heard , RS:BAE+,B/L crepts IAA, ISA , P/A: soft , non tender , CNS: HMF intact , NAD.
A : HFREF(EF:42%) with MODERATE LV dysfunctional, CKD(stage V), DM+ , HTN+. P:
1.Head end elevation up to 30degree 2.02 supplementation
3.fluid restriction less than 1 litre per day
4. salt restriction
5.inj. LASIX 40mg/IV/BD
6.tab.CARDIVAS 3.125 mg PO/OD
7.tab. VILDAGLIPTIN 50mg PO OD 8.tab.TAMSULOSIN-D 0.4mg PO OD
9.tab. NODOSIS 500mg PO BD 10.tab.ECOSPRIN-AV 75/20 mg OD
11.tab. HYDRALAZINE 12.5mg PO OD
12.Neb with IPRAVENT , BUDECORT
13.Syp. ASCORYL 10ml PO TID
14.DAILY WEIGHT MONITORING
15.STRICT I/O CHARTING
16.MONITOR VITALS
DAY 2:
SOAP NOTES : AMC CUBICLE BED.
S: no fresh complaints, NO fever spikes.
O: pt is conscious , coherent , cooperative
BP:100/80mmhg.
Temp : 101F,
PR:116 bpm ,
spo2:98%on RA.
CVS: S1S2 heard ,
RS:BAE+,B/L crepts IAA, ISA ,
P/A: soft , non tender ,
CNS: HMF intact , NAD.
A : HFREF(EF:42%) with MODERATE LV dysfunctional, CKD(stage V), DM+ , HTN+.
P:
1.Head end elevation up to 30degree 2.02 supplementation if spo2 <95
3.fluid restriction less than 1 litre per day
4.salt restriction
5.inj. LASIX 40mg/IV/BD
6.tab.CARDIVAS 3.125 mg PO/OD 7.tab. VILDAGLIPTIN 50mg PO OD 8.tab.TAMSULOSIN-D 0.4mg PO OD
9.tab. NODOSIS 500mg PO BD 10.tab.ECOSPRIN-AV 75/20 mg OD
11.tab. HYDRALAZINE 12.5mg PO OD
12.Neb with IPRAVENT , BUDECORT
13.Syp. ASCORYL 10ml PO TID
14.DAILY WEIGHT MONITORING
15.STRICT I/O CHARTING
16.MONITOR VITALS
17.T.OSELTAMAVIR 75mg PO BD
PLANNING FOR DISCHARGE
He got admitted with us twice
First admission in February elog
https://jeeharikasahu.blogspot.com/2021/02/60-year-old-male-with-complaints-of.html?m=1
Second admission elog - in October
https://roshnajilla.blogspot.com/2021/09/60year-old-male-with-hfpef.html?m=1
This is his third admission
https://ranjith119.blogspot.com/2021/11/hello-guys-this-is-online-e-log-book-to.html
