42 year old male electrician came to casuality with chief complaint of

 

October 20, 2021

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I have 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.

42 yr old male electrician, came to casualty with cheif complaint of 

1. SOB grade 4 , progressed from grade 3 since 4-5days 

2.abdominal distension since 4-5 days

3. Bilateral pedal edema upto ankle since 4-5 days .

1yr back diagnosed as TB , used medication for 4days and stopped.

Patient was apparently asymptomatic till July 21 when he was admitted here in Kims ,nkp, with symptoms of SOB , pedal edema ,

 diagnosed as HFrEF with EF= 32% , with COPD, with LEFT ULCER ON FOOT managed conservatively with diuretics, beta blockers , one episode of AF ( paroxysmal) resolved.

Patient continued to consume alcohol 15days after discharge with increased binge drinking since 10days , followed by cough, productive, no diurnal variation , associated with low grade fever and SOB , progressed to grade 4 gradually, associated with orthopnea , with abdominal distension and bilateral pedal edema upto ankle.

Not a k/c/o diabetes/ hypertension/ asthma/epilepsy.

K/c/o alcoholic 180ml whiskey/day since 20yrs .

Gutka consumption since 20yrs.

No similar complaints in the past.

Past history:

2018:

His left foot big toe got hit by iron rod during work, used pain killers but did not subside , foot got swollen the next day, he came to our hospital that day , skin flap from right thigh is grafted to his left foot. He used regular medication for given period. He was fine till 2yrs, then got diagnosed for TB , used medication only for 4days . 

Now before 3months , he got admitted due to jaundice in our hospital, after admission,next day he developed ulcers on left foot ankle, treatment was being given, now again multiple ulcers were developed.

Chronic alcoholic 180ml/day whiskey since 20yrs.

Before 2018 , he was fine with his routine work life.

O/E

Patient is conscious, coherent,co operative.

Afebrile

BP: 90/60mmhg

PR- 112bpm

RESP. RATE: 34CPM

Spo2: 89% room air

CVS:

Parasternal heave +

Apex - visible, diffuse.

S1,S2 heard.

RESP.SYS:

 Dyspnea- grade 4

Wheeze + , bilateral end inspiration.

Position of trachea - central

Adventitious sounds :

Rhonchi + , rales+ , in bilateral ISA . 

PER ABDOMEN:

Soft,Distended.

No any tenderness.

Shifting dullness+

Bowel sounds heard.

CNS : NAD.

INVESTIGATIONS:

 Serum creatinine: 2.1

Blood urea : 75

Serology: negative

2D ECHO:

 Moderate to severe TR+ with PAH : mild MR+ , trivial AR + 

Global akinetic , no AS/MS 

severe LV dysfunction.

No diastolic dysfunction, 

No LV clot. 

PROVISIONAL DIAGNOSIS:

HFrEF with EF=27% ? Beri Beri

With h/o paroxysmal AF (resolved)

With Right sided pleural effusion, secondary to 

     ? Consolidation- CAP

                               - TB

     ? Heart failure

With AKI (?pre renal ) - cardiorenal type 2

With left non healing ulcer over foot , DM - , HTN - .

with h/0 TB ( defaulter ) used medication for 4 days.

TREATMENT:

1. 02 Inhalation @ 4Litres/min.

2.propped up posture.

3.fluid restriction < 1liter/day

4. Salt restriction < 2gm/day

5.Inj. Lasix 40mg / i.v / TID 

    If SBP > 100mmhg.

6.Tab. Ecospirin-Av 75/20mg OD

7. Inj. Thiamine 3amp /i.v / in 100ml NS stat  

8. Neb with IPRAVENT , DUOLIN /stat 

IPRAVENT= 8th hourly

BUDECORT = 12th hourly.

9. Strict I/o monitoring.

10. BIPAP intermittently every 2hrs.

11.Foleys catheterization

12.Inj. Lasix 10amp (vials) 

      20ml.lasix + 30ml NS= 200mg.

      1ml= 200/50= 4mg.

At 2ml/hr ( 8mg/hr).

13. T. Met Xl 25mg /po/stat

14. Inj. HYDROCORTISONE 100mg/i.v /stat

PLEURAL TAP DONE .

19/10/2021 INVESTIGATIONS

Plueral fluid analysis

Volume -3ml

Appearance- clear

Colour- pale yellow

Total count- 10cells

DC= 100% L

RBC - nil

Others- nil

20/10/2021

SOAP NOTES DAY 3

ICU BED 2: 

S - 

Sob decreased from grade 4 to grade 2 . 

c/o nocturnal cough and cough agrravated on lying down. 

No fever spikes 

Swelling in left upper limb,thrombophlebitis.

O - 

Patient is conscious,coherent,co operative

pallor+

No icterus,cyanosis,clubbing, lymphadenopathy

BP- 110/70 mmhg on NA -2 ml/hr

PR- 100 bpm , normal volume , irregular

RR - 20/min. 

Spo2-98% at room air

CVS: S1 S2 heard,no murmers

RS: NVBS +, coarse crepts + in bilateral ISA,SSA,MSA

P/A: soft non tender

GRBS: 90mg/dl

I/O: 1400/500mL

CNS: HMF intact.

A: 

HFrEF with EF=27% secondary to ACUTE DECOMPENSATION ON CHRONIC HEART FAILURE with h/o paroxysmal AF (resolved)

- with RT. PLEURAL EFFUSION ( secondary to consolidation ?CAD ? TB) 

- with CARDIORENAL TYPE 2 syndrome

- left non healing ulcer on left foot

- h/o ? TB (DEFAULTER) used medication for 4 days only

- with COPD with CLD

P:

1.head end elevation

2.oxygenation to maintain SPO2>90%

3.fluid restriction < 1lt/day

4.salt restriction<2gm/day

5.inj .lasix 10amp(vials) in 30ml NS at 3ml/hr

6.T.MET XL 25mg/po/od if SBP >110mmhg,HR> 100/min

7.Inj . Hydrocortisone 100mg bd

8.Neb- with IPATROPIUM - 8th hrly

                    BUDECORT - 12th hourly

9.BIPAP - 2nd hrly

10.inj.thiamine 2amp in 50ml NS/iv/TID

11.T. Ecospirin-Av 75/20mg /po/od

12.syp. GRILLINCTUS 10ml/po/TID

13.protein powder 2tbsp in 100ml milk/TID

Plan : pleural fluid analysis

          LDH awaited

          Plueral protein- transudative.

20/10/2021 INVESTIGATIONS: