86yr old male with SOB AND FEVER
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MUSKAAN GOYAL
ROLL NO. 92
October 19, 2021
A 86 year old male presented to the casuality on 18/10/2021 with chief compliants of
SOB since 4 days which was grade 4
ORTHOPNEA since 4 days and
FEVER since 1 day
HISTORY :
Patient was apparently asymptomatic 10 years back and then he had a prick on his left foot which he hasn't noticed for two days nd gradually developed swelling over the limb associated with fever and he was taken to local RMP and was told he had infection nd was refered to our hospital . Here it was diagnosed as a non healing ulcer and after a week he was taken to a hospital in Hyderabad for further evaluation and grafting was done and it was unsuccessful and since then he gets dressing for the ulcer daily till date. Attenders have given a history of ulcer getting infected frequently.
2 years back patient developed SOB which was grade 3 and cough and orthopnea and was taken to a hospital at Hyderabad and was diagnosed to have a heart failure with minimum circulatory efficiency. Since then he is on regular medication .
2 months back patient has developed infection in the ulcer and generalized edema over the body for which he was taken to a hospital in Hyderabad and was told that he had infection in whole body nd was admitted and treated for 5 days nd was discharged . He was on medication for infection , the family members had taken opinion from a known doctor in Nalgonda and as the patient was not able to take up too many medications for infection as well as heart failure , the doctor advised them to stop medication for heart failure.
Now after 1-2 months of stoppage of medication patient developed SOB 4 days back which was grade 4 . Pateint had taken nebulization since four days in night due to increase sob at night.it was associated with orthopnea . Since a day pateint complaint of fever which was high grade which required tepid sponging.
HISTORY OF PAST ILLNESS:
No h/o DM , HTN, EPILEPSY,TB
PERSONAL HISTORY:
Diet : mixed
Appetite : decreased
Sleep: disturbed due to orthopnea
Bowel and bladder : regular
GENERAL EXAMINATION:
Pt. is consicous , cooperative and oriented to time place person
Thin built , moderately nourished
Pallor present
No icterus, cyanosis , clubbing , lymphadenopathy , edema
Vitals: at the time of admission
BP: 140/80mmhg
PR : 121 beats per min
RR: 21cycles per min
SPO2- 87 % at room air
GRBS - 149mg%
SYSTEMIC EXAMINATION:
Cardiovascular system:
Inspection:
Shape of the chest normal
Trachea appears to be central
No visible apex beat
No engorged veins or pulsations
No visible parasternal heave
RAISED JVP NOTICED
Palpation:
All inspection findings confirmed
Trachea is Central
Apex beat felt at 6th intercoastal space lateral to midline of clavicle
No parasternal heave
All peripheral pulses felt
Auscultation:
S1 S2 not much appreciated..heard very low
No murmurs
Respiratory system:
Bilateral air entry present
No crepts
CNS:
Higher functions intact
Sensory, motor system normal
Per abdomen:
Soft and non tender
Bowel sounds heard
INVESTIGATION:
Hemogram , 2D echo , ECG , clotting time bleeding time , RFT , LFT, ABG
Ecg on 18/10/2021
Ecg on 19/10/2021
Ecg on 20/10/2021
Referal from surgery in relation to the ulcer:
PROVISIONAL DIAGNOSIS:
HFrEF with left foot non healing ulcer
TREATMENT:
1.)Head end elevation upto 30°
2.)Fuild restriction upto 1 lit / day
3.)Salt restriction < 2.5 g/ day
4.)Inj Neomol 100 ML IV / if temp > 101° F
5.)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 1.25 mg / po/od
8.)Inj Hydrocortisone 100 mg / iv stat
9.)Inj lasix 10 ampules ( 200 mg ) in 30 ml NS at 2 ml / hr
10.)Dressing for Left LL ulcer
11) Moniter vitals
SOAP NOTES :
AMC Bed 1
Unit I admission
SOAP notes Day 2
19/9/21
S : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt is symptomatically improved
O/E
Pallor +
JVP +
PR 130 bpm
BP 100/70 mmHg
RR 28 cpm
Temp 98.6 F
CVS :
JVP elevated
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
B/L INSPIRATORY CREPTS IN ISA,IAA
B/L EXPIRATORY WHEEZE IN IAA,ISA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD
A:
HFrEF with EF 45% secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
With MAT ( Multifocal Atrial Tachycardia )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
5)Inj Lasix infusion @ 1ml/hr
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 1.25 mg / po/bd
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
INJ lasix infusion 10 ampules in 30 ml NS
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj hydrocort 100 mg / IV /TID
SOAP notes Day 3
20/10/21
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt has tachycardia
O/E
Pallor +
PR 105 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.6 F
CVS :
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
B/L INSPIRATORY CREPTS IN ISA,IAA
B/L EXPIRATORY WHEEZE IN IAA,ISA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj hydrocort 100 mg / IV /TID
Plan Any rate control agents to be added as patient is experiacing sob whenever he is having tachycardia(mat) adequate bronchodialtors are given
SOAP notes
DAY 4
21/10/21
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt has tachycardia
O/E
Pallor +
PR 90 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.4 F
GRBS 170 mg/dl
CVS :
Jvp increased
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
NVBS +
COARSE CREPTS IN B/L ISA,IAA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj lasix 40 mg iv/bd
SOAP notes
DAY 5
22/10/21
Fever chart :
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