60 yr old female with chest pain

60 year old female with chest pain.














August 24,2021


Seemala Anjali 

3rd sem

Under the guidance of Dr.Sowmya intern



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 60 year old female came to casuality with chief complaints of chest pain since 2 hours, shortness of breath since 4 hours and palpitations since 4 hrs.



HISTORY OF PRESENT  ILLNESS:

Patient was apparently asymptomatic till mrng, then she was planned for an elective procedure of intrathecal steroid injection for SCIATICA in the afternoon.  She took her morning dose of tab.METXL 50mg, CLOPITAB tabs, FELMA 40mg.
But procedure was postponed due to high BP( 200/100 mm Hg.) 

She stopped taking her regular medication ecosprin since 6 days, for the elective procedure .

After procedure was cancelled , she returned home and ate lunch. She was feeling DISCOMFORT AND UNEASY and took ecosprin tablet , Sobitrate 5mg in the evening .

She developed FEVER, CHILLS , RIGOR ( high grade fever).

 
H/O:  Shortness of breath : III -IV with   SWEATING since 2hrs.

H/O: PALPITATIONS (+)
H/O: CHEST PAIN (+) since 1 hr
H/O  Dry cough since evening.
NO H/O Orthopnea and pnd.


Took medication METXL- 50mg, ECOSPRIN-150 mg, SOBITRATE -5mg.

HISTORY OF PAST ILLNESS:

K/C/O:      

  •  HTN
  • PTCA
TREATMENT HISTORY:

  • HTN: on regular medication( METXL 50mg)
  • Diabetes: no
  • CAD : no
  • Asthma :no
  • On regular medication ( ECOSPRIN) but stopped since 6 days.
PERSONAL HISTORY:

  • Married
  • Occupation: stays at home
  • Appetite: normal
  • Bowels: normal
  • Micturition: normal
  • No known allergies 
  • No addictions.
FAMILIAL HISTORY:

  • Diabetes : no
  • HTN: no
  • Heart disease: no
  • Stroke: no
  • Cancer: no
  • TB : no
  • Asthma:no
  • No other hereditary diseases.
PHYSICAL EXAMINATION:

GENERAL EXAMINATION:

  • Pallor: no
  • Icterus: no
  • Cyanosis:no
  • Clubbingof fingers /toes:no
  • Lymphedenopathy: no
  • Edema of feet : yes (mild)
  • Malnutrition : no
  • Dehydration  :no
VITALS:
  • Temperature: 103° F
  • Pulse rate: 60 bpm ( normal volume, irregular).
  • RR : 24 breaths per minute 
  • BP : 200/100 mm hg.
  • Spo at room air: 93 %
  • GRBS: 194 mg%
SYSTEMIC EXAMINATION:

  • CVS:
  • Cardiac sounds S1 & S2 are present. 
Respiratory system: BAE (+)

PA: Soft , non tender

CNS : conscious
           Glasgow scale : NAS

PROVISIONAL DIAGNOSIS:

Paroxysmal AF COMMUNITY ACQUIRED PNEUMONIA 


INVESTIGATIONS:

ON day 1:

ABG:

  • PH    :  7.440
  • Pco2 :  29.5 mm hg
  • Hco3 : 19.7. mmol/l
  • St HCO3 : 21.5 mmol/l
  • Po2 : 61.1 mm hg
  • So2  : 91.7 %
SERUM ELECTROLYTES 
  • Sodium: 137 mEq /l
  • Potassium: 4.3 mEq /l
  • Chloride : 94mEq/ l

TROPONIN-1 : negative

COMPLETE BLOOD PICTURE:
  • Haemoglobin: 8.4 gm/dl
  • TLC: 17200 cells / cu.mm
  • PCT : 1.93 lakhs/cu.mm

 RBS : 87 mg/ dl

Blood urea: 40 mg/dl

Serim creatinine: 1.7 mg/ dl

LFT:

  • Total bilirubin: 2.08 mg/dl
  • Direct bilirubin: 0.70 mg/dl
  • SGOT :16 IU/L
  • SGPT: 13IU/L
  • ALP: 186 IU/L
  • TOTAL PROTEINS : 5.8gm/dl
  • Albumin: 3.27 gm/dl
  • A/G ratio: 1.29
DENGUE 

  • NS 1 antigen : negative
  • IgM , IgG : negative.
  • Blood for M.P - STRIP test : negative

URINE EXAMINATION:

  • Albumin : present
  • Sugar: nil
  • Pus cells : 3 to 4
  • Epithelial cells : 2to 3
  • Blood cells : present.
RT-PCR NEGATIVE. 
 
ECG
 

On day 1


 

On day 2



 

 

On day 3


On day 5:


On day 6:


TREATMENT:

On day 1: 

  • Inj ceftriaxone 1gm/IV/ BD
  • Inj pantop 40mg/IV/OD
  • Syp Ascoril 15ml/po/TID
  • Tab Pcm 650mg/po/TID
  • Inj neomol 4gm/IV 
  • Tepid sponging ,temp charting
  • Oxygen inhalation if required to maintain SpO2>92%
  • Tab telma 40mg/po/OD
  • Tab clopitab 75mg/po/OD
  • Tab atorvas 20mg/po/HLS
  • BP charting 
  • I/o charting
  • PR-SpO2/GRBS charting
  • Tab metxl 50mg/po/OD
  • Inj Lasix 20mg/IV/stat
  • Neb budecort , mucomist 12th hrly
On day 2

  • O2 inhalation if required to maintain SpO2>92%
  • Tepid sponging, temp charting
  • Inj ceftriaxome 1gm/IV/BD
  • Inj pantop 40 mg/po/od
  • Tab metxl 50 mg/po/od
  • Tab telma 40mg/po/OD
  • Tab ecospirin 75mg/po/od
  • Tab clopidogrel 75mg/ po/ od
  • Tab atrovas 20mg/po/H/s
  • Tab pcm 500mg/po/TID
  • Inj neomol 1gm /IV/180S if temp >101°F
  • Neb budecort , mucomist 12th hrly
  • Thrombophobe ointment for L/A
  • Thyronorm 25 microgram/po
Tab metxl 25mg/po.
On day 3 
  • O2 inhalation if required to maintain SpO2>92%
  • Tepid sponging, temp charting
  • Inj pantop 40 mg/po/od
  • Tab metxl 50 mg/po/od
  • Tab ecospirin 75mg/po/od
  • Tab clopidogrel 75mg/ po/ od
  • Tab atrovas 20mg/po/H/s
  • Tab pcm 500mg/po/TID
  • Inj neomol 1gm /IV/180S if temp >101°F
  • Neb budecort , mucomist 12th hrly
  • Thrombophobe ointment for L/A
  • Thyronorm 25 microgram/ po
  • Tab telma 40mg/po
  • Tab metxl 25mg/po
On day4 
 
  • O2 inhalation if required to maintain SpO2>92%
  • Tepid sponging, temp charting
  • Inj.Ceftriaxone 1gm/Iv/BD
  • Inj pantop 40 mg/po/od
  • Tab metxl 50 mg/po/od
  • Tab ecospirin 75mg/po/od
  • Tab clopidogrel 75mg/ po/ od
  • Tab atrovas 20mg/po/H/s
  • Tab pcm 500mg/po/TID
  • Inj neomol 1gm /IV/180S if temp >101°F
  • Neb budecort , mucomist 12th hrly
  • Thrombophobe ointment for L/A
  • Thyronorm 25 microgram/ po
  • Tab telma 40mg/po.
  • Syp. Ambroxol po/BD 5ml.
  • Tab metxl 25mg/po
On day 5

  • O2 inhalation if required to maintain SpO2>92%
  • Tepid sponging, temp charting
  • Inj.Ceftriaxone 1gm/Iv/BD
  • Inj pantop 40 mg/po/od
  • Tab metxl 50 mg/po/od
  • Tab ecospirin 75mg/po/od
  • Tab clopidogrel 75mg/ po/ od
  • Tab atrovas 20mg/po/H/s
  • Tab pcm 500mg/po/TID
  • Inj neomol 1gm /IV/180S if temp >101°F
  • Neb budecort , mucomist 12th hrly
  • Thrombophobe ointment for L/A
  • Thyronorm 25 microgram/ po
  • Tab telma 40mg/po.
  • Syp. Ambroxol po/BD 5ml.
  • Syp.Mucaine gel 2tbspoons /po
  • Inj.clexane 40 mg SC /OD
  • Tab metxl 25mg/po
On day 6

  • O2 inhalation if required to maintain SpO2>92%
  • Tepid sponging, temp charting
  • Inj.Ceftriaxone 1gm/Iv/BD
  • Inj pantop 40 mg/po/od
  • Tab metxl 50 mg/po/od
  • Tab ecospirin 75mg/po/od
  • Tab clopidogrel 75mg/ po/ od
  • Tab atrovas 20mg/po/H/s
  • Tab pcm 500mg/po/TID
  • Inj neomol 1gm /IV/180S if temp >101°F
  • Neb budecort , mucomist 12th hrly
  • Thrombophobe ointment for L/A
  • Thyronorm 25 microgram/ po
  • Tab telma 40mg/po.
  • Syp. Ambroxol po/BD 5ml.
  • Syp.Mucaine gel 2tbspoons /po
  • Inj.clexane 40 mg SC /OD
  • Tab metxl 25mg/po.




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