2nd INTERNAL ASSESSMENT

A 80 yr old M with SOB since 3 days

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER

 

Chief complaints:

         A 80 year old male came to casuality with chief complaints of :

        -SOB grade IV and altered sensorium since 3 days

History of presenting illness:

         Patient was apparently asymptomatic 5 months back then he developed altered sensorium for which he was treated in our hospital and diagnosed to have uremic encephalopathy due to acute kidney injury caused by lower UTI. He was treated under OP basis.

         Then 3 days ago attendees noticed that patient was tachypneic and doing mouth breathing and was taken to local RMP and told to have BP 200/100 and was brought to local hospital with complaints of altered sensorium -not speaking,responding to commands since 3 days. No complaints of fever, seizures,headache,decreased UO,pedal edema.

He was admitted on 2/12/22 in the morning.

He was sedated and intubated and after sometime he went into cardiac arrest and revived with CPR. He was put on inotropes.

After ABG reports was found to have acidosis  and underwent dialysis at 5:30 pm.

Past history : 

There is a history of similar complaints 1 yr back when he developed altered sensorium and got admitted in our hospital ,diagnosed to have metabolic encephalopathy and got treated for that and discharged after 3 to 4 days.

No history of DM,HTN,ASTHMA,CAD

Personal history:

Diet-mixed

Appetite-decreased

Bowel and bladder -involuntary since 3 days

Sleep- adequate

Addictions- stopped smoking and alcohol 10 yrs back

General phycial examination 

The patient was examined in a well lighted room 

The patient was unconscious and under sedation thin built and nourished 

Pallor - present 

No icterus 

No cyanosis

No clubbing 

No lymphadenopathy 

No edema

Vitals at 4pm

Temperature : 98.6 ° F

BP : 70/50

PR :100 bpm

RR :14 cpm

SpO2 : 98 % with 100 fiO² 

GRBS : 113 mg/dl

Systemic examination 

Respiratory : 

Inspection : 

No visible scars and sinuses 

Some hypopigmented spots are present

Chest appears bilateral symmetrical and elliptical in shape

Trachea is central in position with endotracheal tube in it

No dilated veins 

And is having central line 

Palpation : all inspectory findings are confirmed 

Apical impulse is felt in 5th intecostal space 

On percussion 

Dullness is seen in all areas.

 Auscultation:

Crepitus heard

Crepts ad heard in IMA, IAA , ISA

CNS 

Patient is unconscious 

And is on sederion at 4 pm 

And at the time of admission CNS findings 

GCS : E2V1M1 ( 4/15 )

Pupils : b/l nsrl

Tone : normal in all 4 limbs

Power : not elisitable 

Reflexes : 

                      (R).         (L)

Biceps          1+.          1+

Triceps         2+.         1+

Supinator     1+.          -

Knee             1+.          2+

Ankle             1+.          1+

Plantar     Mute   Flexion

Abdomen : 

On inspection 

Shape : scaphoid 

 Umbilicus : central , inverted

Equal movements in all quadrants with desperation 

Visible pulsations seen under xiphoid sternum 

No scars and sinus

No localized swellings

On palpation 

No masses palpated 

No organomegaly

On percussion 

Tympanic note is seen 

On auscultation

Bowel sounds are heard 

No local lymphadenopathy

Provisional diagnosis: acute pulmonary edema and uremic encephalopathy with chronic renal failure.

INVESTIGATIONS:

At 12:30 pm

Treatment:

Air bed

Inj.Atracurium 5ml/hr(undiluted)

Inj.Medazolam 5ml/he

Inj NORAD 15 ml/ hr acc to MAP

RT feeds 100ml milk + protein powder 4th hrly,200 mo free water 4th hrly

Inj. Pantop 40mg iv OD

Tab.NODOSIS 500 mg RT/TID

Tab. Shelcal RT/OD

Cap bio D3 RT OD weekly once

Inj lasix20mg iv BD

GRBS 4th hrly monitoring

Inj NaHCO3 100 mg +100 ml NS