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.
A 63 year old male came to the casuality with the chief complaints of pedal edema since 4 days and facial puffiness since 2 days. He also complained of shortness of breath, decreased urine output and decreased appetite since two days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic four days ago when he developed facial puffiness which was sudden in onset and was gradually progressive.
Patient also developed pedal edema of pitting type ,2 years ago which was insidious in onset and was persistent ,but gradually progressed to the present state four days ago.
Patient also complains of SOB which was insidious in onset, gradually progressed from grade 2 to grade 3 NYHA.
No history of orthopnoea and PND.
PAST HISTORY:
Patient has a history of right sided hemiparesis secondary to CVA. It was treated conservatively with antiplatelet drugs which he was using on and off. He was able to walk after the treatment.
He is also a k/c/o Hypertension since 1 1/2 year for which he is on regular medication ( Tab. Met XL )
He is also a k/c/o Diabetes since three years for which he's on Human Actrapid 15U--×--8U.
He is also a k/c/ o CKD 1 year ago for which he was managed conservatively and was not on hemodialysis.
He is also a k/ c/ o CAD since one year.
Not a k/c/o TB, Asthma ,epilepsy.
PERSONAL HISTORY:
Apetite: decreased
Diet: mixed
Sleep: Inadequate
Urine output: decreased
Constipation is present
Addictions: Patient was an alcoholic. Stopped alcohol 2 years ago.
No known allergies.
PHYSICAL EXAMINATION:
General examination
Consent was taken. Patient was examined in well-lit room. Patient has altered sensorium.
He is afebrile.
BP : 160/90 mm of Hg
Pulse rate : 97 bpm
Respiratory rate: 26 cpm
SpO2: 98%
He has pallor.
Edema : present ( Anasarca)
Icterus, Clubbing, Cyanosis, Kolionychia Lymphadenopathy - absent.
SYSTEMIC EXAMINATION
CVS : S1 S2 heard (muffled)
Diffuse apex beat.
No murmurs or thrills heard.
Respiratory system :
BAE+ , decreased B/L breath sounds.
B/L Crepts were heard.
Dyspnoea of grade III
PER ABDOMEN:
Distended, Soft, non tender
Free fluid +
Scrotal swelling is present.
CNS:
No abnormalities detected.
INVESTIGATIONS:
ECG:
Hemogram:
TLC- 6000
PLC- 2.09 lakhs
CUE:
Alb- +++
Sug- trace
PC- 3-5
EC- 2-4
RBS- 184 mg/dl
HbA1C- 6.7 %
Urea-139
Creat-5.3
Uric acid-5.8
Na-141
K-5.6
Cl-101
TB- 0.94
DB- 0.13
AST- 10
ALT- 09
ALP- 308
TP-5.1
Alb- 2.5
A/G- 1.02
ABG:
PH- 7.124
pCo2- 29.4
PO2- 116
HCO3- 9.3
Spot Urine protein creat ratio- 4.97
Urinary Na- 198
Urinary K- 16.5
Urinary Cl- 409
-HIV, HbSAg, HCV, RAT for COVID 19- negative
X Ray chest:
Rt sided pleural effusion with consolidation.
2D echo:
EF- 32%
Severe LV dysfunction
Dilated all chambers
IVC dilated ( 2.25 cms )
USG :
RT gross pleural effusion
Lt moderate pleural effusion
Gall bladder sludge +
B/L grade II RPD
Moderate ascites.
Acute LVF ( secondary to HTN) on chronic heart failure ( secondary to CAD) with right sided pleural effusion.
K/c/o Chronic kidney disease
K/c/o DM, HTN, CAD.
Treatment:
Fluid restriction
Inj Lasix 40 mg / IV / Stat followed by inj Lasix 20 mg @ 2.5 ml / hr
Inj Pantop 40 mg IV/OD
Inj Zofer 4 mg IV/SOS
Nebulisation with duolin and budecort 8th hourly
Tab Ecosprin AV ( 75/ 20 ) PO/ H/S
Tab Amlong 10 mg PO/ H/S
Inj HAI S/C pre meal acc to sliding scale
Vitals monitoring 2- hourly
GRBS monitoring 4th hourly
Weight monitoring daily
Foleys catherisation done
Pleural tap done I/v/o Rt sided gross pleural effusion - 1000 ml was tapped
Pleural fluid analysis:
Sugar- 198
Protein- 0.7
LDH- 154
Transudative pleural effusion.
Post pleural tap X- ray.
And hyperkalemia ( serum K -6 )
Hemodialysis was done for 3 hours on 9/11/21 and 10/11/21
Ultrafiltrate removed- 500 ml
On 11/11/ 12
SOB and edema decreased.
Pt is c/c/c
Temp-99.0F
Bp: 130/80 mmhg
PR: 96 Bpm regular, normal volume.
CVS: S1S2+, no murmers.
RS: NVBS+ , DECREASED BREATHSOUNDS IN RT IAA,ISA.
P/A: soft,non tender
GRBS: 158 mg/dl
I/O: 700ml/500 ml
SPO2: 98% @ RA
CNS: HMF INTACT
ABG:
PH: 7.278
PCO2: 39.1
PO2: 70.0
HCO3: 17.7
HEMOGRAM:
HB: 7.5
TC: 6,100
PLT: 1.5 lakhs
RFT:
UREA: 73
CREATININE: 3.3
UA: 3.6
Ca: 7.6
Po4: 3.4
Na: 148
K: 4.0
Cl: 101
ACUTE LVF ( secondary to HTN) ON CHRONIC HEART FAILURE (secondary to CAD).
with k/c/o CVA,CKD since 1yr
HTN since 2 years
DM since 2 yrs
With RIGHT SIDED PLEURAL EFFUSION ( TRANSUDATIVE)
With REFRACTORY METABOLIC ACIDOSIS ( RESOLVING)
with REFRACTORY HYPERKALEMIA ( RESOLVING).
With ANEMIA
Plan:
Salt restriction < 2.4 gm/day
fluid restriction < 1lit/day
Inj. Lasix 40mg/i.v / TID
Inj.HAI PRE MEAL
8AM - 2PM - 8PM
Inj. Iron sucrose 1amp in 100ml
Inj Erythropoietin SC/ weekly once
Nebulisation with duolin and budecort
Tab Amlong 10 mg PO H/S
Tab Ecosprin AV ( 75/20) PO/H/S
Tab Met XL 50 mg PO/OD
Tab Metolazone 10 mg PO/BD
Tab Shelcal PO/OD
AMC bed 7, Unit 1
63/M
Day 5( 12/11/21)
S:
SOB decreased
EDEMA decreased
No fever spikes.
(2 sessions of hemodialysis done )
O:
Pt is c/c/c
Temp-97.6F
Bp: 110/90 mmhg
PR: 82 Bpm regular, normal volume.
CVS: S1S2+, no murmers.
RS: NVBS+ , DECREASED BREATHSOUNDS IN RT IAA. Coarse crepts + in RT ISA and MSA
P/A: soft,non tender
GRBS: 110 mg/dl
I/O: 900ml/550 ml
SPO2: 98% @ 4L O2
CNS: HMF INTACT
ABG:
PH: 7.323
PCO2: 38.3
PO2: 85.8
HCO3: 19
A:
ACUTE LVF ( secondary to HTN) ON CHRONIC HEART FAILURE (secondary to CAD).
with k/c/o CVA,CKD since 1yr
HTN since 1 and half yr
DM since 3yrs
With RIGHT SIDED PLEURAL EFFUSION ( TRANSUDATIVE)
With REFRACTORY METABOLIC ACIDOSIS ( RESOLVING)
with REFRACTORY HYPERKALEMIA ( RESOLVING).
With ANEMIA
P:
Salt restriction < 2.4 gm/day
fluid restriction < 1lit/day
Inj. Lasix 40mg/i.v / TID
Inj.HAI PRE MEAL
8AM - 2PM - 8PM
Inj. Iron sucrose 1amp in 100ml
Inj Erythropoietin SC/ weekly once
Nebulisation with duolin and budecort
Tab Amlong 10 mg PO H/S
Tab Ecosprin AV ( 75/20) PO/H/S
Tab Met XL 50 mg PO/OD
Tab Metolazone 10 mg PO/BD
Tab Shelcal 500 mg PO/OD
AMC bed 7, Unit 1
65/M
Day 6 ( 13/11/12)
S:
Facial puffiness +
Pedal edema +
SOB decreased
No fever spikes.
2 sessions of hemodialysis done
O:
Pt is c/c/c
Temp-98.4F
Bp: 130/70 mmhg
PR: 98 Bpm regular, normal volume.
CVS: S1S2+, no murmers.
RS: NVBS+ , DECREASED BREATHSOUNDS IN RT IAA and ISA
P/A: soft,non tender
GRBS: 164 mg/dl
I/O: 800ml/950ml
SPO2: 98% @ 4L O2
CNS: HMF INTACT
ABG:
PH: 7.285
PCO2: 43.3
PO2: 127
HCO3: 19.9
HEMOGRAM
Hb-7.0
TLC-5,700
PLC-1.5 lakhs
RFT :
Urea-97
Creat -4.1
UA-4.7
CA-8.0
PO4-3.8
Na-148
K-4.1
Cl-103
A:
ACUTE LVF ( secondary to HTN) ON CHRONIC HEART FAILURE (secondary to CAD).
with k/c/o CVA,CKD since 1yr
HTN since 1 and half yr
DM since 3yrs
With RIGHT SIDED PLEURAL EFFUSION ( TRANSUDATIVE)
With REFRACTORY METABOLIC ACIDOSIS ( RESOLVING)
With REFRACTORY HYPERKALEMIA ( RESOLVED)
With ANEMIA
P:
Salt restriction < 2.4 gm/day
fluid restriction < 1lit/day
Inj. Lasix 40mg/i.v / TID
Inj.HAI PRE MEAL
8AM - 2PM - 8PM
Inj. Iron sucrose 1amp in 100ml
Inj Erythropoietin SC/ weekly once
Nebulisation with duolin and budecort
Tab Amlong 10 mg PO H/S
Tab Ecosprin AV ( 75/20) PO/H/S
Tab Met XL 50 mg PO/OD
Tab Metolazone 10 mg PO/BD
Tab Shelcal PO/OD
Plan for hemodialysis with PRBC transfusion
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