33 year old male patient with complaints of shortness of breath

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE DISCUSSION

A 33 year old male came to the casualty on 17sep 

Chief complaints of sob since 3 days. ( 14sep)

Fever since 10 days

Cough since 10 days

Chest pain since 10 days

Pain abdomen since 10 days

HOPI : 

Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. 

He developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed to  grade 4 , SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days

Past History :

Admitted to a hospital for pain abdomen for 4 days

Not a k/c/o HTN, DM, CAD, ASTHMA, EPILEPSY, THYROID DISEASE. 

Personal history:

Constipation since 4 days

Appetite : decreased

Sleep : disturbed

Chronic alcoholic since 10 years, alcohol consumption increased since past 6 months. Consumes half bottle of whiskey daily since past 6 months. Last consumed 10 days back. 

Family History : No significant family history.

On examination:

Moderately built and moderately nourished. 

Vitals ( 22 sep)

BP -  90/70mm Hg

SpO2 - 96 , on 15 lit of O2 - 71

RR - 37 cpm

PR - 127

Temp - 98 F

On 17sep

BP - 100/80 mm Hg

SpO2 - 22 , on 15 lit of O2 - 71

RR - 66 cpm

PR - 127

Temp - 99 F, 103 F 

                                                 INVESTIGATIONS

 

                                            1. Blood Grouping and Rh typing

                                   

                                                   2. Hemogram

 

                                                                      17sep 

 

 

3. RFT

 

On 17 sep

 

 

 

 

 

                                 4. LFT 

 

                           5. RBS 

 

                                                                    6. ABG

 

 

                                                                     Sep 17

 

                                             Sep17- CPAP mode

 

 

 

 

                                                         Sep 22

 

7. Serum amylase

 

8. Serum lipase

 

 

9. Chest x-ray

 

sep 17

 

Sep 19

 

sep21

 

 

 

10. 2D echo

                            2D echo

                                                                      Sep 17

 

                                              Sep22

2D echo showing vsd

 

 

11. Ultrasound scan abdomen 

 

12. RT-PCR

 

13. Anti HCV Antibodies 

 

14. Anti HbsAg

 

 

15. CUE

 

16. ECG

 

 

 

                                                                                          Sep17

 

 

                                         Sep21

17. HRCT chest

 

 

18. Culture and sensitivity report 

 

 

19. Serum Electrolytes : 

 

                                        Sep21

20. APTT

 

21. PT, INR

. 

 

Soap notes

Sep 21

 

S:

Patint is on ventilation

 

O:

Ventilator settings :

FiO2 - 70, PEEP-8, RR- 22, SpO2-94 

Vitals :

Bp: 80/60 mm Hg(Ionotropic supports - Dobutamine and Noradrenaline) 

PR: 46 bpm

RR: 40 cpm

Temp: 100.4 F

GRBS: 177 mg/dl

Cvs: S1 S2 +

RS- BAE +

P/A- soft, non tender

CNS- NAD

 

A: 

Community acquired pneumonia (sepsis with MODS)

 

P:

1. RT FEEDS (4TH HOURLY MILK, 2ND HOURLY WATER)

2. INJ. NEOMOL 1 G IV IF TEMP. >102 °F

3. T. DOLO 650 MG RT/TID

4. NEBULIZATION WITH SALBUTAMOL 

5. INJ. PIPTAZ 2.25 MG IV BD

6. INJ. NORADRENALINE 2 AMPOULES IN 45 ML NS 5ML/HR

7. INJ. DOBUTAMINE 1 AMPOULE IN 45 KL NS 4 ML/HR

8. INJ. HAI 10U IN 25% D

9. INJ. 10% 10 ML CALCIUM GLUCONATE IV OVER 10