37 year male with SOB



 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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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.


Complaints : 


39 years male came with chief complaints of SOB since 10am today.


History of presenting illness:


Patient was apparently asymptomatic till today morning, after freshup he drank ragi java and took medication prescribed by us during discharge. Then he suddenly developed shortness of breath (grade-4).


Past history:


F/U/C/O sepsis secondary to left LL cellulitis (resolving) HFmEF (EF-48%) with AKI on CKD with anemia (NC/NC) secondary to ? CKD with Thrombocytopenia with known case of DM2 since 12 years and k/c/o hypertension since 2 years. 

S/P H/O Rays amputation of Right toe (great).

S/P fasciotomy left foot 13/5/23.

3 sessions of hemodialysis were done.


Personal history:


APPETITE NORMAL

DIET MIXED

BOWELS & BLADDER REGULAR

SLEEP ADEQUATE

NO KNOWN ALLERGIES 

NO SIGNIFICANT FAMILY HISTORY


GENERAL EXAMINATION 


Patient is C/C/C

BP-120/80mmHg

PR-104bpm

RR-28cpm

GRBS-580mg/dl

Temperature- 97.9F

Spo2-98% on Room Air


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Diagnosis:


 UNCONTROLLED SUGARS (?DIABETIC KETOACIDOSIS-UNRESOLVED) LEFT LL CELLULITIS (RESOLVING) HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO

? CKD WITH THROMBOCYTOPENIA WITH K/C/O DM SINCE 12 YEARS

K/C/O HYPERTENSION SINCE 2 YEARS WITH 2FFP TRANSFUSION

1 SESSION OF HEMODIALYSIS

S/P RAYS AMPUTATION OF GREAT TOE

S/P FASCIOTOMY OF LEFT FOOT ON 13/5/23


Treatment :


  1. Inj. PIPTAZ 2.25g IV/TID
  2. Inj. METROGYL 500mg IV/TID
  3. IVF NS at 50 ml/hr
  4. Inj. HUMAN ACTRAPID INSULIN 
  5. Inj. PAN 40mg IV/OD
  6. Inj. LASIX IV/BD If SBP > 110mmhg
  7. T.NODOSIS 500mg BD
  8. T.OROFER-XT PO/OD
  9. T.SPOROLAC DS PO/TID
  10. MONITOR VITALS BP,PR,RR,spo2 EVERY HOURLY
  11. GRBS CHARTING 7• PROFILE
  12. T.RACECODOTRIL 100mg IV/TID
CLINICAL IMAGES









INVESTIGATIONS



















REFERRALS:








SUMMARY


Diagnosis:


 UNCONTROLLED SUGARS (?DIABETIC KETOACIDOSIS-UNRESOLVED) LEFT LL CELLULITIS (RESOLVING) HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO

? CKD WITH THROMBOCYTOPENIA WITH K/C/O DM SINCE 12 YEARS

K/C/O HYPERTENSION SINCE 2 YEARS WITH 2FFP TRANSFUSION

1 SESSION OF HEMODIALYSIS

S/P RAYS AMPUTATION OF GREAT TOE

S/P FASCIOTOMY OF LEFT FOOT ON 13/5/23


Complaints : 


39 years male came with chief complaints of SOB since 10am today.


History of presenting illness:


Patient was apparently asymptomatic till today morning, after freshup he drank ragi java and took medication prescribed by us during discharge. Then he suddenly developed shortness of breath (grade-4).


Past history:


F/U/C/O sepsis secondary to left LL cellulitis (resolving) HFmEF (EF-48%) with AKI on CKD with anemia (NC/NC) secondary to ? CKD with Thrombocytopenia with known case of DM2 since 12 years and k/c/o hypertension since 2 years. 

S/P H/O Rays amputation of Right toe (great).

S/P fasciotomy left foot 13/5/23.

3 sessions of hemodialysis were done.


Personal history:


APPETITE NORMAL

DIET MIXED

BOWELS & BLADDER REGULAR

SLEEP ADEQUATE

NO KNOWN ALLERGIES 

NO SIGNIFICANT FAMILY HISTORY


GENERAL EXAMINATION 


Patient is C/C/C

BP-120/80mmHg

PR-104bpm

RR-28cpm

GRBS-580mg/dl

Temperature- 97.9F

Spo2-98% on Room Air


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Treatment :


  1. Inj. PIPTAZ 2.25g IV/TID
  2. Inj. METROGYL 500mg IV/TID
  3. IVF NS at 50 ml/hr
  4. Inj. HUMAN ACTRAPID INSULIN 
  5. Inj. PAN 40mg IV/OD
  6. Inj. LASIX IV/BD If SBP > 110mmhg
  7. T.NODOSIS 500mg BD
  8. T.OROFER-XT PO/OD
  9. T.SPOROLAC DS PO/TID
  10. MONITOR VITALS BP,PR,RR,spo2 EVERY HOURLY
  11. GRBS CHARTING 7• PROFILE
  12. T.RACECODOTRIL 100mg IV/TID


COURSE AT THE HOSPITAL


PATENT WAS ADMITTED IV/O SOB GRADE 3-4 INSIDIOUS IN ONSET GRADUALLY

PROGRESSIVE AND ON FURTHER EVALUATION,WAS FOUND TO HAVE HIGH SUGARS WITH GRBS 580 (URINE FOR KETONE BODIES- NEGATIVE) DUE TO NON COMPLIANCE TO MEDICATION WITH ABG SHOWING SEVERE METABOLIC ACIDOSIS.INJNAHCO3 5OMEQ

STAT F/B 50MEQ IN 100ML NS. INJ.HAI 6U IV STAT GIVEN INFUSION 6ML/HR INSULIN

INFUSION GIVEN ACCORDING TO ALGORITHM 1 FOR 1 DAY LATER SHIFTED TO S/C INSULIN

ACCORDING TO THE REQUIREMENT .TLC COUNT ELEVATED AND WAS STARTED ON INJ.PIPTAZ AND INJ METROGYL. SURGERY REFERAL WAS DONE ON 19/5/23 IV/O LEFT LOWER LIMB S/P FASCIOTOMY ,SKIN OVER THE LEFT LIMB EDEMATOUS AND SHINY ERYTHEMA + LOCAL  RISE OF TEMP+ EXTENDING TILL MID THIGH TO FOOT AND FASCIOTOMY INCISION PRESENT OVER MID THIGH, GRANULATION TISSUE PRESENT ,MINIMAL SLOUGH + SEROUS DISCHARGE PRESENT FROM FASCIOTOMY SITE AND ADVICE FOLLOWED AS PER ORDER AND REGULAR DRESSINGS WITH MGSO4 + GLYCERINE DRESSING DONE

ON DAY 2 PATEINT HAS LOOSE STOOLS (?ANTIBIOTICS INDUCED DIARRHEA AND

ANTIBIOTICS STOPPED)

ON DAY3 ANTIBIOTICS STOPPED AND MANAGED CONSERVATIVELY ON 21/6/23 PATIENT

HAS BEEN TAKEN TO DIALYSIS 1ST SESSION WITH 2FFPS AND 1PRBC TRANSFUSION, C?

UREMIC ENCEPHALOPATHY AND ANURIA)

PREVIOUS H/O SEPSIS SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH HEART

FAILURE WITH MID RANGE EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC /NC)

WITH THROMBOCYTOPENIA


PATIENT WAS DISCHARGED WITH VITALS


TEMP-98.5

BP-140/70

PR-100bpm

RR-16cpm

GRBS-201 at 8:00am


ADVICE AT DISCHARGE


1. TAB PAN 40MG PO/OD

2. TAB LASIX 40MG PO/OD

3. TAB NODSIS 500MG PO/BD

4, TAB.OROFER XT PO/OD

5. TAB.SPOROLAC DS PO/TID

6. TAB RECECOTODRIL 100MG PO/TID

7.Inj.HAI 4U SC/TID.According to grbs via telephone.

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