MEDICINE BIMONTHLY ASSIGNMENT - MAY 2021

 Bhavani vegesena

Roll no 141

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.

Case: 55 year old female came to the OPD with the chief complaints of:-

          Shortness of breath since 4days.

          Fever since 2 days.

          Vomitings since 1day.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 4days back and then developed:

Shortness of breath which was of grade 4 and was not associated with orthopnea or PND.

Fever since 2days was persistent and low grade and was not associated with chills and rigor.

Vomitings since 1 day with 5-6 episodes.it was non projectile , non bilious and food particals as content and was associated with abdominal pain.

The patient also complained of decreased appetite since 3days.

HISTORY OF PAST ILLNESS:

There were no similar complaints in the past.

The patient is a known case of:

Diabetes mellitus since 6years on TAB GLIMI-M2

Asthma since 4years

Pulmonary kochs 3years back and used ATT for 6months.

MEDICAL HISTORY:

The patient took both the doses of COVISHIELD vaccine against COVID.

PERSONAL HISTORY:

Apettite: decreased

Diet: mixed

Bowel and bladder: normal

Sleep: adequate 

Addictions: nil

Allergies: nil

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

The patient was conscious, coherent and cooperative , lying on the bed,

She was well oriented to time, place and person.

She is thinly built and moderately nourished.

Vitals:

On admission were:

BP: not recordable

PR: 121BPM

RR: 22CPM

Spo2: 98%

GRBS: 254

No pallor, icterus, cynosis, clubbing, lymphaedonopathy and oedema.

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard , no thrills, no murmurs

RESPIRATORY SYSTEM: dyspnoea present ( grade 4)

No wheeze

BAE positive , NVBS

PER ABDOMEN: soft, non tender

 BS sluggish

INVESTIGATIONS:

On admission

Ur : 63

Cr:1.9

UA:4.9

SERUM ELECTROLYTE 

Na-138

K-4

Cl-98

Aftr 1 session of dialysis (7pm)

Ur : 93

Cr:3.2

UA:3.9

SERUM ELECTROLYTE 

Na-134

K-3.9

Cl-98

post dialysis ( next morning)

Ur : 83

Cr:3.1

UA:3.9

SERUM ELECTROLYTE 

Na-134

K-3.9

Cl-98

on 26/10/21

Ur : 152

Cr:4.9

UA:5.8

ca-7

SERUM ELECTROLYTE 

Na-135

K-3.9

Cl-106

abg on 26/10/21

ph-7.249

pco2-28.4

po2-152

Amylase 46

Lipase 24

ECG:

XRAY:

2D ECHO:

      SERUM ELECTROLYTES:

    

PROVISIONAL DIAGNOSIS:

PRE -RENAL AKI  (RESOLVING) 2° to DEHYDRATION with HYPOVOLEMIC SHOCK with 

ALCOHOLIC KETOACIDOSIS (RESOLVED) with WERNICKES ENCEPHALOPATHY (RESOLVING) with 

ACUTE HEART FAILURE with EF-45% with REFRACTORY METABOLIC ACIDOSIS (RESOLVING)

with H/O PULMONARY KOCH'S (3Y BACK) with 

K/C/O ASTHMA (4Y BACK) with K/C/O DM(6Y BACK)

TREATMENT:

IVF 4 NS - bolus 

Inj Nor adrenaline 8ml/hr ( 2amp in 47 ml NS)

IVF NS,RL @ 100 ml /hr continuos 

Inj Sodium Bicarbonate 100meq /iv/ stat - 50 meq in 100 ml NS /IV / slow infusion over 2 hours 

Inj PANTOP 40 mg /iv /od 

Inj neomol 100ml /sos 

Inj ZOFER 4mg /IV / OD 

Inj Ceftriaxone 1 gm /iv/ bd 

Inj HAI (39 ml NS with 40 IU HAI ) 

Inj Sodium Bicarbonate 1 amp in 100 ml NS /Stat 

Inj Piptaz 4.5 gm /IV/Stat- Inj Piptaz 2.25 gm /IV / TID

Acute kidney injury:

It is also referred red to as acute renal failure. It describes the situation where there is a sudden and often reversible loss of renal function and on , which develops over days or weeks and is usually accompanied by reduction in urine volume.