CBBLE UDHC SIMILAR CASES
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
PATIENT C/O BREATHLESSNESS AND CHEST PAIN SINCE 4 DAYS , DRY COUGH SINCE 3 DAYS [OCCASSIONALLY].
HOPI:-
PT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK THEN HE PRESENTED WITH BREATHLESSNESS WHICH IS SUDDEN IN ONSET[MMRC GR-III] ASSOCIATED WITH WHEEZE AND INCREASED ON LYING DOWN.
BREATHLESSNESS RELIEVED ON SITTING POSITION.
H/O COUGH + SINCE 3 DAYS , WITHOUT EXPECTORATION. DIURNAL VARIATION
CHEST PAIN SINCE 4 DAYS, NOT ASSOCITED WITH SWEATING, NONRADIATING. DRAGGING TYPE. NO POSTURAL VARIATION.
LOSS OF APPETITE +
NO H/O FEVER, CHEST TIGHTNESS , HEMOPTYSIS.
PAST H/O:
H/O SIMILAR COMPLAINTS IN THE PAST FOR WHICH HE USED ORAL MEDICATION AND INHALERS [ROTAHEALER WITH ROTACAP] FOR A WEEK.
H/O TB 20YRS BACK. USED ATT IRREGULARLY.
H/O ASTHMA 10 YRS BACK
NOT A K/C/O HTN ,DN,CAD
NO H/O COVID 19
DRUG H/O:
USED ATT 20 YRS BACK IRREGULARLY.
USED INJ.PIPTAZ BD FOR 5 DAYS
PERSONAL H/O:
MARRIED
DIET - MIXED,
APPETITE -DECREASED ,
BOWEL MOVEMENT - REGULAR
BLADDER MOVEMENTS - NORMAL
NO ADDICTIONS
NO KNOWN DRUG ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
ON EXAMINATION
PEDAL EDEMA PRESENT
NO SIGNS OF PALLOR ,ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY,
VITALS AT ADMISSION
TEMP: AFEBRILE
PR: 92 BPM
BP:100/70 MMHG
SPO2: 95% ON RA
GRBS: 110mg%
RR: 42CPM
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD, NO MURMURS HEARD
PER ABDOMEN: SOFT, NONTENDER
CNS : NAD
RESPIRATORY SYSTEM :
INSPECTION: SHAPE OF THE CHEST- ELLIPTICAL
TRACHEA APPEARS TO BE CENTRAL
RR 42 CPM
ACCESSORY MUSCLES REPIRATION +
NO DROPPING OF SHOULDER
SPINOSCAPULAR DISTANCE EQUAL ON BOTH SIDES
PALPATION:
ALL INSPECTORY FINDINGS CONFIRMED
NO LOCLAL RISE OF TEMP
NO TENDERNESS
TRACHEA CENTRAL IN POSITION
PERCUSSION:
DIRECT: RESONANT
INDIRECT:RESONANT
AUSCULTATION:
BAE+
VBS: HEARD
B/L RONCHI +
INVESTIGATIONS :-
ABG 22-04-2022 08:07:AM
PH 7.43
PCO2 42.2
PO2 75.4
HCO3 27.9
St.HCO3 27.7
BEB 3.8
BEecf 3.9
TCO2 56.3
O2 Sat 94.2
O2 Count 15.7
ABG 22-04-2022 06:01:PM
PH 7.43
PCO2 34.9
PO2 64.0
HCO3 23.1
St.HCO3 24.1
BEB -0.3
BEecf -0.6
TCO2 47.7
O2 Sat 91.9
O2 Count 13.1
ABG 22-04-2022 09:40:PM
PH 7.41
PCO2 39.3
PO2 65.9
HCO3 24.4
St.HCO3 24.7
BEB 0.4
BEecf 0.3
TCO2 51.3
O2 Sat 92.6
O2 Count 12.0
ABG 23-04-2022 03:25:PM
PH 7.32
PCO2 44.5
PO2 139
HCO3 22.5
St.HCO3 21.9
BEB -3.0
BEecf -2.6
TCO2 46.0
O2 Sat 97.4
O2 Count 17.3
ABG 24-04-2022 06:25:AM
PH 7.35
PCO2 39.3
PO2 83.5
HCO3 21.3
St.HCO3 21.6
BEB -3.4
BEecf -3.3
TCO2 45.2
O2 Sat 95.5
O2 Count 12.5
ABG 24-04-2022 07:17:PM
PH 7.37
PCO2 42.3
PO2 68.3
HCO3 24.0
St.HCO3 23.8
BEB -0.7
BEecf -0.5
TCO2 50.5
O2 Sat 93.8
O2 Count 12.7
ABG 25-04-2022 07:05:AM
PH 7.37
PCO2 44.8
PO2 61.7
HCO3 25.5
St.HCO3 24.8
BEB 0.6
BEecf 0.8
TCO2 53.3
O2 Sat 92.6
O2 Count 13.0
ABG 25/4/22 5PM
ABG 26/4/22 10AM
RFT 22-04-2022
UREA 35 mg/dl
CREATININE 1.0 mg/dl
URIC ACID 2.4 mg/dl
CALCIUM 10.0 mg/dl
PHOSPHOROUS 3.3 mg/dl
SODIUM 141 mEq/L
POTASSIUM 3.9 mEq/L
CHLORIDE 102 mEq/L
LIVER FUNCTION TEST (LFT) 22-04-2022
Total Bilurubin 0.65 mg/dl
Direct Bilurubin 0.20 mg/dl
SGOT(AST) 14 IU/L
SGPT(ALT) 11 IU/L
ALKALINE PHOSPHATE 101 IU/L
TOTAL PROTEINS 5.8 gm/dl
ALBUMIN 2.8 gm/dl
A/G RATIO 0.93
COMPLETE BLOOD PICTURE (CBP) 22-04-2022
HAEMOGLOBIN 11.0 gm/dl
TOTAL COUNT 10900 cells/cumm
NEUTROPHILS 76 %
LYMPHOCYTES 15 %
EOSINOPHILS 02 %
MONOCYTES 07 %
BASOPHILS 00 %
PLATELET COUNT 6.10
SMEAR Normocytic normochromic with thrombocytosis
HBsAg-RAPID Negative
Anti HCV Antibodies - RAPID Non Reactive
23-04-2022
SERUM CREATININE 1.0 mg/dl
SERUM ELECTROLYTES
SODIUM 146 mEq/L
POTASSIUM 3.5 mEq/L
CHLORIDE 103 mEq/L
COMPLETE BLOOD PICTURE (CBP)
HAEMOGLOBIN 8.7 gm/dl
TOTAL COUNT 10800 cells/cumm
NEUTROPHILS 89 %
LYMPHOCYTES 07 %
EOSINOPHILS 01 %
MONOCYTES 03 %
BASOPHILS 00 %
PLATELET COUNT 5.05
SMEAR Normocytic normochromic anemia with reactive neutrophilia
25/4/22
SERUM ELECTROLYTES (26-4-22):-
SODIUM 148 mEq/L
POTASSIUM 3.7 mEq/L
CHLORIDE 101 mEq/L
D DIMER 970 MCG/ML(22/4/22)
TROPONIN I: NEGATIVE
PT:16S
APTT:32S
INR:1.11
BT:2 MIN
CT: 4MIN 30SEC
CXR
2D ECHO
MIXED TR+ : TRIVIAL AR + ; NO MR
GOOD LV SYSTOLIC FUNCTION +
SCLEROTIC AV, NO MS/AS ; NO RWMA
DIASTOLIC DYSFUNCTION ; MILD PAH +
USG ABDOMEN
USG LEG
E/O DIFFUSE SUBCUTANEOUS EDEMA NOTED OVER ANKLE AND UPTO 5 CMS ABOVE TO IT
ATA , PTA AND DPA SHOWS MONOPHASIC WAVEFORM WITH DAMPENED FLOW.
ANTERIOR AND POSTERIOR TIBIAL VEINS ARE NORMAL
POPLITEAL ARETRY AND VEIN NORMAL
XRAY ANKLE AND KNEE RIGHT
ECG
SPUTUM C/S:-
TREATMENT GIVEN:-
1] IVF 1 NS @ 50ML/HR
2]INJ.PAN 40MG OD [BBF]
3]INJ.SLIDENAFIL 25MG BD
4]INJ.DERIPHYLLINE IV BD
5]INJ.HYDROCORT 100MG IV BD
6]INJ.PIPTAZ 4.5G IV TID
7]O2 INHALATION WITH NASAL PRONGS @ 2-3L/MIN
8]CPAP INTERMITTENTLY WITH SETTING
FIO2-30, PEEP-5
9]NEB DUOLIN QID ; BUDECORT TID ; MUCOMIST 4TH HRLY
10]TAB.MONTAC LC HS/OD
11]TAB AZEE 500MG PO OD
12]TAB.PCM 650MG SOS
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