45 YEAR OLD FEMALE WITH FEVER AND SOB
T.AKSHITHA REDDY This is an online Elog book to discuss our patient’s deidentified health data shared after taking his/her’s 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 patient’s clinical problems with collective best evidence based inputs.
45 year old female with fever and sob
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.
45 yr old female came to casuality with the cheif complaints of
- SHORTNESS OF BREATH since 15days
- FEVER with chills and rigors since 15 days
History of presenting illness
SHORTNESS OF BREATH Associated with breathlessness while lying down(ORTHOPNEA)since 15days
C/O FEVER WITH CHILLS AND RIGORS since 15days
No diurnal variation.
Subsided on taking medication.
past history
Not a k/c/o HTN, DM, ASTHMA, TB, EPILEPSY, THYROID.
No similar complaints in the past.
Family history
No significant family history.
Personal history:
Takes mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements.
No known allergies.
Not an alcoholic.
not a smoker.
O/E:
Pt is c/c/c
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temp:103°f
Bp: 100/80mmhg
Pr: 144bpm
RR: 28cpm
SPO2: 97% RA
GRBS: 285mg/dl
SYSTEMIC EXAMINATION:
CVS:
S1 S2 heard
No murmurs
RESPIRATORY SYSTEM:
DYSPNEA GRADE 4-GRADE 3.
No wheeze.
Trachea position-central.
Vesicular breath sounds heard
PER ABDOMEN
Soft , non tender
Shape: scaphoid.
Bowel sounds heard .
CNS:
No abnormalities detected
Clinical images:
Investigations:
29/11/21
LFT
Total bilirubin :1.40
direct bilirubin :0.55
SGOT:202
SGPT :31
ALP :163
Albumin :2.9
A/G :0.91
ABG
PH: 7.44
PCO2 : 30.1
HCO3 : 20.3
st.HCO3 : 22.3
O2 sat :867
RFT
urea- 4.9
creatinine -1.0
uric acid -3.8
ca. -10.0
phosphorus -2.7
Na -138
K- 4.1
cl - 92
Random blood sugar(RBS) :304
PROVISIONAL DIAGNOSIS:
community acquired pneumonia
?atypical pneumonia
?denovo diabetes mellitus
Treatment given :
O2 supplementation if spo2<90%
Head end elevation upto 30°
Nebulization with IPRAVENT, BUDECORT 2 ampules 8th hrly.
Tab. Dolo 650mg po/TID
Inj.Augmentin 1.25gm i.v/BD
Tab.Pan 40mg po/OD.
Inj. Neomol 100mg I.V if temp >101.1f
MONITOR VITALS 2nd hrly
Temp charting 4th hrly
GRBS charting 4th hrly.
Day1
30/11/21
S : Fever spike +
SOB +
O/E :
Pt is conscious,coherent ,cooperative
Temp: 103 F
Bp: 100/ 70mmhg
Pr: 120 bpm
RR: 24 cpm
SPO2: 87 % RA
GRBS: 268 mg/dl
SYSTEMIC EXAMINATION:
CVS:
S1S2+
No murmurs
RS:
DYSPNEA (GRADE 4-GRADE 3.)
No wheeze.
Trachea position-central.
Vesicular breath sounds heard
Per abdomen:
Soft, non tender
Shape: scaphoid.
Bowel sounds heard .
CNS:
no abnormalities detected
Treatment given:
O2 supplementation if spo2<90%
Head end elevation upto 30°
Nebulization with IPRAVENT, BUDECORT 2 ampules 8th hrly.
Tab. Dolo 650mg po/TID
Inj.Augmentin 1.25gm i.v/BD
Tab AZITHROMYCIN 500 mg /OD
Tab.Pan 40mg po/OD.
Inj. Neomol 100mg I.V if temp >101.1f
MONITOR VITALS 2nd hrly
Temp charting 4th hrly
GRBS charting 4th hrly.
Day 2
1/12/21
S :Fever spike+
Sob+
O/E:
Pt is conscious, coherent,cooperative
Temp:101.5 °f
Bp: 100/60mmhg
Pr: 122bpm
RR: 45cpm
SPO2: 97% RA
SYSTEMIC EXAMINATION
CVS:
S1S2 heard
No murmurs
RS:
DYSPNEA (GRADE 4-GRADE 3.)
No wheeze.
Trachea position-central.
Vesicular breath sounds heard
Per abdomen:
Soft, non tender
Shape: scaphoid.
Bowel sounds heard .
CNS:
no abnormalities detected
Investigations :
ABG
PH : 7.39
Pco2 :29.4
PO2 : 77.7
HCO3 :17.5
st.HCO3 : 19.6
RFT
Ca-10.0
P- 2.7
Na -138
K -4.1
Cl -92
LFT
Total bilirubin -1.09
Direct Bilirubin -0.50
SGOT-162
SGPT-97
HbA1c -7.1
PLBS -253mg/dl
Treatment given:
O2 supplementation if spo2<90%
Head end elevation upto 30°
Nebulization with IPRAVENT, BUDECORT 2 ampules 8th hrly.
Tab. Dolo 650mg po/TID
Inj.Augmentin 1.25gm i.v/BD
Tab AZITHROMYCIN 500 mg /OD
Tab.Pan 40mg po/OD.
Inj. Neomol 100mg I.V if temp >101.1f
MONITOR VITALS 2nd hrly
Temp charting 4th hrly
GRBS charting 4th hrly.
Day3
2/12/21
S: intermittent sob+,
fever spikes -
headache b/l frontal+
Neck pain +
O/E-conscious ,coherent,cooperative
afebrile
PR- 100/min
RR-26min
BP-110/70mmhg
Spo2-92%RA
GRBS:158mg/dl
SYSTEMIC EXAMINATION
CVS:
s1s2+
RS:
bae +,end inspiratory wheeze in all areas
Crepts + in rt ssa ,axillary areas
PER ABDOMEN:
Obese,
Bowel sounds heard
CNS:
no abnormalities detected
Investigations
ABG
PH :7.39
PCO2 ;31.4
HCO3 :18.6
St.HCO3 : 20.2
Treatment given:
Oxygenation if spo2<92
Injection augmentin 1.2gm/iv/bd
Nebulization with budecort ,ipravent
tab azithromycin 500mg/po/od
Tab pcm 650mg po tid
grbs 6th hourly
bipap intermittently
Day 4
3/12/21
S: sob subsided,
Fever spikes -
headache b/l frontal+
Neck pain +
O/E: pt is conscious,coherent,cooperative
afebrile
PR- 94/min
RR-22min
BP-120/70mm Hg
GRBS-169mg/dl
SYSTEMIC EXAMINATION
CVS:
s1s2+
R.S:
Bilateral air entry +
P/A:
obese
Bowel sounds heard
CNS:
no abnormalities detected
Treatment given:
Oxygenation if spo2<92
injection augmentin 1.2gm/iv/bd
Nebulization with budecort ,ipravent
tab azithromycin 500mg/po/od
Tab pcm 650mg po tid
grbs 6th hourly
bipap intermittently
