86yr old male with SOB AND FEVER

 This is an online E log book to discuss our patient's   

de-identified health data shared after taking her 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 current best evidence based inputs.

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 : 




S: : decrease in SOB 
No fever episode . 

O : Pt is conscious ,coherent, cooperative 

O/E 
Pallor + 
PR 80 bpm
BP 110/70 mmHg 
RR 22 cpm
Temp 98.4 F 
GRBS 123 mg/dl
Weight 43 kgs 

CVS : 
Jvp + 
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) Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
9) Dressing for Left LL ulcer 
10) Moniter vitals 
11) Strict I/o charting 
12) 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 























Comments

Popular posts from this blog

Bimonthly Clinical Case Assignment 1

INTERNSHIP ASSESSMENT ROLL NO: 97-120

A 78YEAR OLD MALE WITH SHORTNESS OF BREATH, CHEST PAIN, B/L PEDAL EDEMA AND FACIAL PUFFINESS