A 65 YEAR OLD FEMALE

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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.

A 65 year old woman, came to the casuality with chief complaints of 

1.Fever since 10 days 

2.Pain abdomen since 5 days 

3.SOB since 5 days 

4.Loss of appetite since 5 days 

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 10 days back, then she developed fever which is sudden in onset, high grade,intermittent not associated with chills and rigor and relieved on taking medication.Fever associated with headache which is dull in nature. 

H/O of vomitings 10 days back 3 episodes/day, which is non projectile,non bilious ,non foul smelling, non blood tinged with food particles as content (for 3 days). 

H/O of loose stools 10 days back which is watery in consistency, 2-3 episodes/day, non blood stained ,that lasted for 3 days 

C/o pain abdomen since 5 days in the epigastric region,associated with abdominal discomfort, bloating sensation and loss of appetite 

Shortness of breath since 5 days, which was gradually progressed from ( grade 3 - 4) 

For the above mentioned complaints she first went a local hospital in nalgonda where she was treated conservatively for 5 days. There on (7/09/21) she was found to have sr creat 5.2 mg/dl and urea 82 mg/dl. HRCT chest was done revealing bronchitis with mild pleural effusion, CT abdomen & pelvis showed b/l radiodense tiny calculi in both kidneys and  hepatomegaly and so the usg abdomen.On 7/9/21 ECG showing normal sinus rhythm with heart rate of 102,on 9/9/21 ECG showing ? svt with heart rate 180bpm ,on 10th ecg showing normal sinus rhythm with heart rate of 82bpm. she was then adviced to visit our hospital i/v/o nephrologist opinion. 

C/O Joint pains of lower limbs since 5 years intermittently, uses pain killers occasionally as adviced by local RMP (? NSAIDS) 

PAST HISTORY : 

Not a k/c/o DM,HTN,TB,CAD/CVA,asthama,thyroid and epilepsy 

No similar complaints in the past 

History of biomass exposure since 40 years 

GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative  

Moderately built and moderately nourished 

No pallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy  

VITALS : 

Temp: afebrile 

PR: 80 bpm 

BP: 130/80 mm hg 

RR: 24 cpm  

Spo2 - 92% at RA  

GRBS - 148 mg/dl  

CVS : 

S1, S2 heard , No murmurs 

RS : 

Position of trachea: central 

Bilateral decreased air entry + 

PER ABDOMEN: 

Abdomen is soft and non tender 

Bowel sounds heard. 

No palpable mass or free fluid  

CNS: 

Patient is Conscious ,oriented to time,place and person 

HMF -intact 

Motor & sensory system: normal 

Reflexes: present 

Cranial nerves: intact 

No meningeal signs 

PROVISIONAL DIAGNOSIS : 

CHRONIC BRONCHITIS

PRE-RENAL AKI

PAROXYSMAL AF (RESOLVED)

?UROSEPSIS

INVESTIGATIONS

Outside reports

ON 11/9/21

ON 12/9/21

On 13/9/21

On 14/9/21

On 15/9/21

On 16/9/21

TREATMENT

ON 11/9/21

1.Salt restriction <2.4 gm/ day
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/TID

4.TAB.DOLO 650 MG/PO/TID

5.INJ NEOMAL 100 ML IV/SOS

6.TAB ULTRACET /PO/QID 

7.Syp.Ascoryl D 15 ml/po/tid
8.pr/bp/rr charting 2nd HRLY
9.I/O charting

ON 12/9/21

1.IVF -NS,RL@150 ML/HR
2.SALT RESTRICTION <2.4 GM/DAY
3.TAB.PANTOP 40 MG/PO/OD

4.INJ.ZOFER 4 MG/IV/TID

5.INJ NEOMAL 100 ML IV/SOS
6.TAB.DOLO 650 MG/PO/TID
7.TAB ULTRACET /PO/QID
8.Nebulisation with DUOLIN 6TH HRLY
   And budecort 12 th HRLY
9.Syp.Ascoryl D 10 ml/po/tid
10.pr/bp/rr charting 2nd HRLY
11.I/O charting

12.GRBS -6TH HRLY

ON 13/9/21

Day 3 

SOAP NOTES

SUBJECTIVE-

Fever 

Body pains

Generalized weakness

OBJECTIVE-

Temp-98.5 F

Pr-105bpm ,regular,bounding pulse

BP- 140/70MM HG

RS-BAE+ , decreased air entry b/l IAA,ISA,Wheeze +

Rr-24cpm

Spo2-93% @RA

CVS-S1,S2 heard

P/A- soft

GRBs-109 mg/dl

Stools-not passed

ASSESSMENT-

?UTI With Pre renal AKI

?chronic bronchitis 

Paroxysmal AF(resolved)

PLAN OF TREATMENT-

1.IVF -NS,RL@100 ML/HR

2.O2 inhalation -4 lit to maintain spo2 

3.Inj.ZOSTUM 1.5 gm/iv/bd

4.TAB.PANTOP 40 MG/PO/OD

5.INJ.ZOFER 4 MG/IV/TID

6.TAB.DOLO 650 MG/PO/TID

7.TAB ULTRACET /PO/QID

8.Nebulisation with ipravent 6TH HRLY

   And budecort 12 th HRLY

9.Syp.Ascoryl D 10 ml/po/tid

10.pr/bp/rr charting 2nd HRLY

11.I/O charting

On 14/9/21

A 65 year old female 

Subjective:

1 episode of vomiting at 4 am today 

Fever spikes from 8am to 2pm yesterday, no fever episodes thereafter

OBJECTIVE-

Temp-98.5 F

Pr-78bpm ,regular,bounding pulse

BP- 120/70MM HG

RS-BAE+ , decreased air entry b/l IAA,ISA

Left iAA,ISA inspiratory crepts+

Rr-24cpm

Spo2-95% @RA

CVS-S1,S2 heard

P/A- soft

GRBs-109 mg/dl

Stools- passed 

ASSESSMENT-

Her creatinine has come down 2.8mg/dl to 1.1mg/dl 

Acute GE with Pre renal AKI

 ?acure bronchitis 

Paroxysmal AF(resolved) 

PLAN OF TREATMENT- 

1.IVF -NS,RL@100 ML/HR

2.O2 inhalation

3. Day 2 of Inj Piptaz 2.5gm gm/iv/TID

Inj Metrogyl 400mg/IV TID 

4.TAB.PANTOP 40 MG/PO/OD

5.INJ.ZOFER 4 MG/IV/TID

6.TAB.DOLO 650 MG/PO/TID

7.TAB ULTRACET  half tab /PO/QID

8.Nebulisation with ipravent 6TH HRLY

   And budecort 12 th HRLY

9.Syp.Ascoryl D 10 ml/po/tid

10.pr/bp/rr charting 2nd HRLY

11.I/O charting

On16/9/21

SOAP NOTES

Subjective:

Generalized weakness
No fever spikes
Cough (reduced)

OBJECTIVE-

Temp-98.3F

Pr-80bpm ,regular,bounding pulse

BP- 140/80MM HG

RS-BAE+ , decreased air entry b/l IAA,ISA

Left iAA,ISA inspiratory crepts+

Rr-20cpm

CVS-S1,S2 heard

P/A- soft

Stools-  not passed

ASSESSMENT-

? acute bronchitis
Paroxysmal AF(resolved)
Pre renal AKI SECONDARY TO acute GE
DENOVO HTN

PLAN OF TREATMENT-

1.IVF -NS,RL@100 ML/HR

2.O2 inhalation

3.TAB.PANTOP 40 MG/PO/OD

4.INJ.ZOFER 4 MG/IV/TID

5.TAB.DOLO 650 MG/PO/TID

6.TAB ULTRACET  half tab /PO/QID

7.Nebulisation with ipravent 6TH HRLY

   And budecort 12 th HRLY
8.Syp.Ascoryl D 10 ml/po/tid

9.pr/bp/rr charting 2nd HRLY

10.I/O charting

On 17/9/21

SOAP NOTES
Ward case

A 65 year old female

Subjective:

No fever spikes
Cough (reduced)

OBJECTIVE-

Temp-98.3F

Pr-84bpm ,regular,bounding pulse

BP- 140/80MM HG

RS-BAE+ , decreased air entry b/l IAA,ISA

Left iAA,ISA inspiratory crepts+

Rr-20cpm

CVS-S1,S2 heard

P/A- soft

Stools- passed

ASSESSMENT-

? acute bronchitis
Paroxysmal AF(resolved)
Pre renal AKI SECONDARY TO acute GE
DENOVO HTN

PLAN OF TREATMENT-

1.IVF -NS,RL@100 ML/HR

2.O2 inhalation

3.TAB.PANTOP 40 MG/PO/OD

4.INJ.ZOFER 4 MG/IV/TID

5.TAB.DOLO 650 MG/PO/TID

6.TAB ULTRACET  half tab /PO/QID

7.Nebulisation with ipravent 6TH HRLY

   And budecort 12 th HRLY
8.Syp.Ascoryl D 10 ml/po/tid

9.pr/bp/rr charting 2nd HRLY

10.I/O charting