A 76 YEAR OLD FEMALE WITH COMPLAINTS OF CHEST PAIN AND SHORTNESS OF BREATH

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE DISCUSSION:

A 76years old female housewife by occupation brought with complaints of 

  • chest pain since yesterday 
  • SOB since morning 

HOPI:

Patient was apparently asymptomatic 2yrs and was diagnosed with hypertension (is on medication not known). 2yrs back was admitted at a private hospital for liver problem- cholelithiasis -done cholecystectomy.

Presently- complained of chest pain since yesterday associated with 2 episodes of Vomiting,Sweating and 2 episodes of loose motions.

Was taken to RMP and was given 1 injection and tablet and brought back to home.

Since today morning she complained of discomfort and was brought to casualty .

PAST HISTORY:

Not a k/c/o - DM,TB,ASTHMA,EPILEPSY

PERSONAL HISTORY:

She is Married
She consumes 
  • Mixed diet 
  • sleep is adequate 
  • Appetite normal
  • bowel and bladder movements are regular

MENSTRUAL HISTORY: attained menopause 15 years back


FAMILY HISTORY:

No similar complaints in family 


GENERAL EXAMINATION:

At time of admission 

Pt is drowsy,extremities were cool and clammy

PR-75bpm

Bp-60/40mmhg

Spo2-57% ON RA

CVS-S1,S2 +, no added sounds 

RS- b/l diffuse crepts on inspiration 

P/A-Soft,NT Scar present at the right hypochondriac region (kochers incision for cholecystectomy)


CLINICAL IMAGES:








INVESTIGATIONS:

2D ECHO: https://youtu.be/D3m0t9MIGxU

ABG:Day1 at 4:40pm



















Serum lactate: 31


PROVISIONAL DIAGNOSIS: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.

TREATMENT:

PT WAS INTUBATED IN VIEW OF HYPOXIA AND CONNECTED TO MECHANICAL VENTILATOR 

In view of cardiogenic shock pt was started on inotropic support

Post intubation vitals:

Bp:90/60MMHG

Pr:140BPM

Spo2:95%

Rr:crepts decreased

Post intubation investigations:



ABG:Day1 at 7:20pm






MEDICATION:

RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.NA 2 AMP IN 40ml NS @ 14ml/hr
Inj.doubutamine 1 amp in 45ml NS @ 15ml/he
Inj.Atracurium
Inj.Lasix 40mg iv/b
Tab Ecosprin AV 75/10 OD
Inj.Clexane 60 mg sc bd
inj.KCL 1amp in 200ml NS over 4 hrs
Vitals are monitored

Comments

Popular posts from this blog

67 YEAR OLD MALE WITH PROGRESSIVE SLOWNESS AND WEAKNESS OF LIMBS

MEDICINE INTERNSHIP