A 45 YEAR FEMALE WITH FEVER, VOMITING AND SHORTNESS OF BREATH

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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.

A 45year female Presented with 

C/O Fever since 5 days

C/O Vomiting since 4 days

C/O Headache since 4 days

C/O Shortness of breath since 2 days

Patient was apparently asymptomatic 5 days back then he developed fever (Sudden in onset gradually progressive ) not associated with chills and rigor, no diurnal variations, no Sweating.

C/O Vomitings Since 4 days (non bilious), non- projectile,food particles as content

C/O shortness of breadth (grade 3) according to NYHA classification, no orthopnea, no PND, no Palpitations.

C/O B/ L Pedal edema (Since Yesterday) Pithing type, not associated with decreased Urine output.

K/C/O HTN Since 4 Months (unknown Medication)

C/O loss of appetite 

C/O On and off fever Since One month (low grade).

No H/O weight loss

Not a k/C/O DM/ TB / epilepsy / Thyroid.

Personal History.: 

Married

Occupation:

Appetite: DECREASED

Diet: Mixed

B&B : Regular

No Addictions

Menstrual History:

Age of Menarche :

cycles:

Family History: 

On General Physical Examination: 

pt is C / C / C, .

Pedal Edema - Present - B/L

JVP: Raised

Cervical lymph nodes - enlarged

No signs of pallor, icterus, cyanosis, clubbing .

Vitals:

Afebrile

PR: 100 bpm

RR: 16 Cpm

BP: 110 / 70 mm Hg

SPO2: 99% at RA

CVS: S1, S2+

RS: BAE +, Rt sided expiratory crepts + at SMA & IMA.

P/A: Soft , NT, BS +

CNS: NAD.

Investigations:

30 / 09 / 21: X-ray chest PA and Lateral view: Right upper lobar Pneumonia with consolidation in posterior basal Segment above the oblique fissure.

On 01 / 10 / 21:

 2d ECHO: EF: 58%, Mild MR+ / AR +, Mild to moderate TR+ with PAH, NO RWMA, No AS/MS, Sclerotic AV, Good LV systolic function, Diastolic dysfunction +, NO PE.

On 01 / 10 / 21: 

ON 02 / 10 / 21: 

 

USG Neck :  

Impression: 1) Diffuse thyroid Disease , 2) Cervical Lymphnodal Enlargement.

On 03/10/21:

On 04/10/21:

On 05/10/21

PD:  RIGHT UPPER LOBE CONSOLIDATION , LOBAR PNEUMONIA, WITH PRE RENAL AKI, ,RIGHT HEART FAILURE, HYPOALBUNEMIA,  AND HYPERTHYROIDISM.

Treatment:  

On 30 / 09 / 21

l. O2  inhalation @ 4 lit/min (if Sp02<92% at RA).

2. Inj. PIPTAZ 4.5 g /IV/TID

|

2.25 gm IV/TID

3.Inj . Pan 40mg IV/OD 

4. T. PCM 650mg PO /TID .

5. Inj. ZOFER  4mg /Iv/BD

6. Syp. Ascoril 10ml  PO /BD 

7. Nebulisation with Duolin-8 th hrly, Budecort-12th hrly

8. Strict I/ 0 Charting

9. GRBS Charting-.8th hrly

10. vitals monitoring 4th hrly

11. IVF-NS, RL @ 75ml/hr. 

 

On 01/10/21:

1.O2  inhalation @ 4 lit/min (if Sp02<92% at RA).

2. Nebulisation with Duolin-8 th hrly, Budecort-12th hrly

3. IVF-NS, RL @ 75ml/hr

4.Inj. PIPTAZ 2.25gm IV/TID

5. Inj . Pan 40mg IV/OD

 6. Inj. ZOFER  4mg /Iv/BD

7. T. PCM 650mg PO /TID

8. Syp. ASCORIL 10ml/ PO/BD 

 9. Temp charting And tepid Sponging

10. Strict I/ 0 Charting

11. vitals monitoring 4th hrly

On 02/10/21 : 

1.O2  inhalation @ 4 lit/min (if Sp02<92% at RA).

2. Nebulisation with Duolin-8 th hrly, Budecort-12th hrly

3. IVF-NS, RL @ 75ml/hr

4.Inj. PIPTAZ 2.25gm IV/TID

5. Inj . Pan 40mg IV/OD

 6. Inj. ZOFER  4mg /Iv/BD

7. T. PCM 650mg PO /TID

8. Syp. ASCORIL 10ml/ PO/BD 

9. Temp charting And tepid Sponging

10. Strict I/ 0 Charting

11. vitals monitoring 4th hrly

 

On 03/10/21:

1.O2  inhalation @ 4 lit/min (if Sp02<92% at RA).

2. Nebulisation with Duolin-8 th hrly, Budecort-12th hrly

3. IVF-NS, RL @ 75ml/hr

4.Inj. PIPTAZ 2.25gm IV/TID

5. Inj . Pan 40mg IV/OD

 6. Inj. ZOFER  4mg /Iv/BD

7. T. PCM 650mg PO /TID

8. Syp. ASCORIL 10ml/ PO/BD

9. TAD.LASIX  20 MG  PO/OD

10. TAB.CARBIMAZOLE 10 mg BD

11. TAB. PROPANOLOL 20mg OD

12.Temp charting 4th hrly And tepid Sponging

13. Strict I/ 0 Charting

14. vitals monitoring 4th hrly

04/10/21:

1.O2 inhalation @ 4 lit/min (if Sp02<92% at RA).

2. Nebulisation with Duolin-8 th hrly, Budecort-12th hrly

3. IVF-NS, RL @ 75ml/hr

4.Inj. PIPTAZ 2.25gm IV/TID

5. Inj . Pan 40mg IV/OD

 6. Inj. ZOFER 4mg /Iv/BD

7. T. PCM 650mg PO /TID

8. Syp. ASCORIL 10ml/ PO/BD

9. TAD.LASIX 20 MG PO/OD

10. TAB.CARBIMAZOLE 10 mg BD

11. TAB. PROPANOLOL 20mg OD

12.Temp charting 4th hrly And tepid Sponging

13. Strict I/ 0 Charting

14. vitals monitoring 4th hrly