70 YEAR OLD MALE WITH EPIGASTRIC PAIN

 Soumya Menda

3rd sem

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.
 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case 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 diagnosis and treatment plan.

CASE SCENARIO:
 
A 70 year old male currently staying at home, stopped walking 3 years ago came to causality with cheif complaints of epigastric pain, swelling in lower limbs ,fever ,cough with sputum and shortness of breath since 4 days.

HISTORY OF PRESENT ILLNESS:
  Patient is apparently asymptomatic than he developed 
  • 4 years back SOB, Pedal edema for while and admitted to hospital and treated
  • 3 years back developed Back pain which was on and off and was on medication [RMP Dr.]
  • Since 2 months he has Back pain and fever
  • Since 1 month he developed SOB, Pedal edema and increase in severity from 10 days
  • Burning micturition and decrease in urine output since 4 days

HISTORY OF PAST ILLNESS:

  K/C/O:
  •  HTN since 1 year and
  •  TB 20 years back
  • CKD  4 years 
Not K/C/O : DM, Asthma, Epilepsy

TREATMENT HISTORY:
 
  • DM: No
  • HTN: On irregular medication since 1 year
  • CKD since 4 years [on irregular medication]
  • Asthma: No ;But has Chronic cough and SOB
  • TB: 20 years back - NO CLEAR HISTORY ?
  • Antibiotics: No
  • Hormones : No
  • Chemo/Radiation: No
  • Blood transfusion : No
  • Surgeries : No
PERSONAL HISTORY: 
  • Married
  • Occupation: currently staying at home 
  • Appetite: Lost
  • Diet: non veg
  • Bowels : Constipation
  • Micturition : Burning and decreased urine output
  • Known allergies : No
  • Addictions : Alcohol - used to consume daily, STOPPED SINCE 3 YEARS 
                                Chronic chutta  smoker [4 - 5 per day] STOPPED SINCE 4 YEARS


FAMILY HISTORY:
  • DM: No
  • HTN: Yes [ he has since 1 year]
  • Heart disease: No
  • Stroke: No
  • Cancer: No
  • TB: Yes [ he has 20 years back]
  • Asthma : No
  • No other hereditary diseases

PHYSICAL EXAMINATION:

 GENERAL EXAMINATION: 
  • Pallor : Yes 
  • Icterus: No
  • Cyanosis: No
  • Clubbing of fingers/ toes : No
  • Lymphadenopathy: No
  • Oedema of feet : yes
  • Malnutrition : Yes 
  • Dehydration: No
  • HR: 84 bpm
  • RR : 20 breaths /min
  • BP: 130/60 mmHg
  • BAE: Present
SYSTEMIC EXAMINATION:
 
 CVS:
  • Thrills: No
  • Cardiac sounds : S1 and S2 are present
  •  Murmurs: Absent
RESPIRATORY SYSTEM:
 
  • Dyspnoea : Yes
  • Wheeze: No
  • Position of trachea: Central
  • Breath sounds: vesicular 

ABDOMEN:
  • Shape of abdomen : Scaphoid 
  • Tenderness: No
  • Palpable mass : No
  • Hernial Orifices: Normal
  • Free fluid : No
  • Bruits :No
  • Liver : Not palpable
  • Spleen : Not palpable 
  • Bowel sounds : Yes 

CNS :
   
  • Conscious
  • Speech : Normal
  • Signs of Meningeal irritation : Neck stiffness - No; Kerning's sign- No
  • Cranial Nerves ,Motor system, Sensory system, Glasgow scale : NAD
  • Cerebral signs : Normal
PROVISIONAL DIAGNOSIS:
    
  • CRF
  • ? VIRAL THROMBOCYTOPENIA
  • ? COPD
INVESTIGATIONS : 
  On day 1 



On day 2





On day 3 

















On day 4















TREATMENT PLAN:

  On DAY 1 

O/E :
  • Pt. C/C/C
  • Temp : Afibrile to touch
  • BP: 130/70 mmHg
  • PR : 82 bpm
  • CVS : S1, S2 present
  • RS: BAE present; B/C Inspiratory crysts ;
  • P/A : Soft , NT
  • CNS : No Functional Neurological Disorder
 1.Fluid restriction - < 2 L/Day 
     Salt restriction < 2 g / Day
2.Inj. Lasix 40 mg IV TID 
     If SBP > 110 mmHg 
3. TAB. Nodosis 500 mg PO TID
4.TAB. Shelcal 500 mg PO TID
5. TAB. Orofer -XT PO BD
6. TAB. Amlong 5 mg PO OD
7. Nebulizer   T. Duolin 8th hrly
     Budecort 12 th hrly
8.Strict I/O charting 
9. GRBS 8 th hrly
10.Monitor vitals 4 th hrly 

 On Day 2
DIAGNOSIS STATE : CRF 
                                       ? Viral Thrombocytopenia
                                       ? COPD
* K/c/o - HTN since 1 year
O/E Patient drowsy and irritable but arousable 
        BP : 120/70 mm Hg
        PR : 142 bpm , regular 
        SPO2 : 98% on  RA
        RR : 35 per min
CVS : S1,S2 are present
RS : BAE present, B/L- diffuse wheeze and stridor present 

*Patient had his first HD session for two hours - evening
After HD --- patient had one episode of   ????? around 10 ml
- Injection : Tranexa 1 amp/IV /STAT
- ABG; RFT; Heamogram; ECG; CXR was sent 
- Inj. NaHCO3 100 meq in 200ml NS/ IV /STAT
- Inj. 3% NaCl infusion @ 10ml per hour for 4 hours
- Remaining CST

ON DAY 3 

DIAGNOSIS STATE : CRF [ ? Analgesic Nephropathy]
                                       ? Viral Thrombocytopenia
                                       ? COPD
* K/c/o - HTN since 1 year
* past H/O  ?????
* Altered state secondary to hyponatremia[? hypervolemic-secondary to CRF]
                                                 hypocalcemia Dyselectrolytemia
O/E 
Pt. conscious and confused 
BP - 130/90 mm Hg
PR - 100 bpm
CVS : S1, S2 are present
RS : BAE present

1. Fluid restriction 1.5 L/Day
2. Inj. PAN 40mg/ IV / OD
3. T.Nodosis 500mg/PO/TID
4. T.Orofer-XT /PO/BD
5. Inj.Ceftriaxone 1g/IV/BD
6. T.Amlong 5mg/PO/OD
7. NEB. Ipravent-8th hrly
               Budecort-12th hrly
8. T.Shelcal 500mg/PO/OD
9. Inform SOS 
10. Inj. 3% NaCl infusion@ 20ml/hr for 4 hours
11. Inj.KCl - 2 amp in 500ml NS/IV/OD

On Day 4

DIAGNOSIS STATE : CRF [ ? Analgesic Nephropathy]
                                       ? Viral Thrombocytopenia
                                       ? COPD
*Altered state secondary to ? hyponatremia [?hypervolemic]
*K/c/o: HTN since one year
*past H/O  ??????
*Hypocalcemia present
      
O/E 
BP: 120/80 mm Hg
PR : 96 bpm
CVS : S1,S2 are present
RS : BAE present 
GRBS : 118 mg/dl

1. Fluid restriction 1.5 L/Day
2. Inj. PAN 40mg/ IV / OD
3. T.Nodosis 500mg/PO/TID
4. T.Orofer-XT /PO/BD
5. Inj.Ceftriaxone 1g/IV/BD
6. T.Amlong 5mg/PO/OD
7. NEB. Ipravent-8th hrly
               Budecort-12th hrly
8. T.Shelcal 500mg/PO/OD
9. Inform SOS 
10. Monitor vitals 4th hrly
11. GRBS 8th hrly
12. Inj. 3% NaCl infusion@ 20ml/hr for 4 hours




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