80 years old male came with the complaints of shortness of breath since 15 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. 

Patient came with the complaints of shortness of breath since 15 days

B/ l pedal edema  and facial puffiness since 3 days

Burning micturition and decreased urine output since 2 days


Patient was apparently asymptomatic 

5 months ago then he developed shortness of breath and visited local doctor and took treatment and then it subsided. Now patient presented with shortness of breath since 15 days, insidious in onset and gradually progressive from grade 1 to grade 3.

Orthopnea present, no PND

No h/o chest pain, palpitations , excessive sweating, giddiness, vomiting.

B/l pedal edema,pitting type, extending up to the knee joint present and facial puffiness present since 3 days

Burning micturition and decreased urine output since 2 days


No h/o fever, cough, cold, vomitings or loose motions

K/c/ o type 2 diabetes mellitus since 6 years on tablet metformin 500 mg po/od


K/c/o HTN since 8 years on tablet metoprolol 0.25 mg po/od


H/o CVA 8 years ago ?TIA took medications for 2 months and stopped. 

Tab. Hydralazine 37.5 mg , Rosuvastatin 10 mg and clopidogrel 

Dytor plus 5 mg

K/c/o alcoholic stopped since 2 years.

Stopped smoking since  6 years

On general examination-

Patient is conscious, coherent, cooperative

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy

B/l Pedal edema present ,pitting type,extending up to the knee joint 

Vitals-

Temp-96. 8F

PR -70 bpm

RR -20 cpm

Bp-130/90 mmhg

Spo2-87% at RA, 100% at 4 lit of O2

Grbs- 186 mg/dl

CVS - S1,S2 present

RS- BAE+, NVBS

Dyspnea present, wheeze present bilaterally

Crepts +

P/A - normal

CNS- 

GCS-E4V5M6

Reflexes- Right.     Left

Biceps.       2+.          2+

Triceps.      1+.          1+

Supinator.    1+.        1+

Knee.            2+.         2+

Ankle.           1+.          1+


Diagnosis - Cardiogenic pulmonary edema (secondary to Heart failure with preserved ejection fraction)?UTI? Renal AKI on CVD with? Severe Anemia ? Nutritional. K/c/o type 2 DM, HTN

Treatment given-

Inj. Lasix 40 mg iv stat given 

Inj. Hai s/c 7 point profile

Tab. Ecospirin Av 78/10 mg OD HS

Tab. Metoprolol 25 mg OD

O2 supplementation to maintain spo2- >94 %

Intermittent CPAP

MONITOR VITALS AND INFORM SOS

BP monitoring 4 th hourly


Investigations -

Hb-4. 7 g/dl

Tlc- 10,700

Neu-87

Lymphocytes -07

Pcv-17. 9

Mcv-65. 6

Mch- 17.2

Mchc-26. 3

Rdw-23. 7

RBC-2. 73

PLC- 4.24


BGT- O POSITIVE

BUN-14. 9

Reticulocyte count- 0.5

S. Magnesium - 1.8

S electrolytes-

Na- 135

K-3. 6

Cl-101

Ca2+- 1.10


B. UREA-32

S creat-1. 6

Rbs-86 mg/dl

Serology - negative 


Chest xray-


ECG-
21/2/23



Ecg-22/2/23



22/2/23 

ICU BED NO-2

UNIT-2

DOA-21/2/23



Patient came with the complaints of shortness of breath since 15 days

B/ l pedal edema and facial puffiness since 3 days

Burning micturition and decreased urine output since 2 days



S-

No fever spikes yesterday

1 unit PRBC transfusion done



O-

Patient is conscious, coherent, cooperative

Vitals-

Temp-99.2F

PR -62 bpm

RR -26cpm

Bp-150/80 mmhg

Spo2- 100% at 2 lit of O2

Grbs- 114 mg/dl

CVS - S1,S2 present

RS- BAE+, NVBS

Crepts + IAA, ISA (b/l)

P/A - soft, non tender, tympanic note present 

CNS- 

GCS-E4V5M6

Reflexes- Right. Left

Biceps. 2+. 2+

Triceps. 1+. 1+

Supinator. 1+. 1+

Knee. 2+. 2+

Ankle. 1+. 1+



Investigations -

Hb-4. 7 g/dl

Tlc- 10,700

Neu-87

Lymphocytes -07

Pcv-17. 9

Mcv-65. 6

Mch- 17.2

Mchc-26. 3

Rdw-23. 7

RBC-2. 73

PLC- 4.24

BGT- O POSITIVE

BUN-14. 9

Reticulocyte count- 0.5

S. Magnesium - 1.8



S electrolytes-

Na- 135

K-3. 6

Cl-101

Ca2+- 1.10

B. UREA-32

S creat-1. 6

Rbs-86 mg/dl

Serology - negative 



ABG-

Ph-7. 489

Po2- 47.9

Pco2-32. 2

Hco3- 25.5

Na- 128

K-2. 5

Ca-0. 43

Cl-91



Lft-

Total bilirubin-0. 80

Direct-0. 19

Ast- 36

Alt-33

Alp-404

T. Proteins-5. 8

Albumin-3. 19

A/G -1.22



A-

Diagnosis - Cardiogenic pulmonary edema (secondary to Heart failure with preserved ejection fraction)?UTI? Renal AKI on CVD with? Severe Anemia ? Nutritional. K/c/o type 2 DM, HTN



P-



Inj. Lasix 40 mg iv bd 

Inj. Hai s/c 7 point profile

Tab. Ecospirin Av 78/10 mg OD HS

Tab. Metoprolol 25 mg OD

Nebulisation with ipravent 12 th hourly

Budecort 12 th hourly

O2 supplementation to maintain spo2- >94 %

Intermittent CPAP

MONITOR VITALS AND INFORM SOS

BP monitoring 4 th hourly



23/2/23 

ICU BED NO-2

UNIT-2

DOA-21/2/23

Patient came with the complaints of shortness of breath since 15 days

B/ l pedal edema and facial puffiness since 3 days

Burning micturition and decreased urine output since 2 days



S-

c/o sob decreased 

No fever spikes yesterday

Stools not passed

2units PRBC transfusion done



O-



Patient is conscious, coherent, cooperative



Vitals- 

Temp-97.6F

PR -73 bpm

RR -20cpm

Bp-150/80 mmhg

Spo2- 99% at 1 lit of O2

Grbs- 93 mg/dl 4 u hai given



 On 21/2/23

8pm- 137 mg/dl

2am-137 mg/dl



On 22/2/23

8 am - 114 mg/dl

2pm- 135 mg/dl inj. Hai 4 u given 

8pm- 72 mg/dl



On 23/2/23

2 am - 125 mg/dl



CVS - S1,S2 present

RS- BAE+, NVBS

P/A - soft, non tender, tympanic note present 

CNS- 

GCS-E4V5M6

Reflexes- Right.     Left

Biceps.       2+.          2+

Triceps.      1+.          1+

Supinator.    1+.        1+

Knee.            2+.         2+

Ankle.           1+.          1+

Investigations -

Hb-7.6 g/dl

Tlc- 14100

Neu-80

Lymphocytes -15

Pcv- 25.9

PLC- 3.7

BGT- O POSITIVE

S electrolytes-

Na- 144

K-3. 2

Cl-100

Ca2+- 1.05

B. UREA-40

S creat-1. 7



22/2/23

Serology - negative

ABG-

Ph-7. 489

Po2- 47.9

Pco2-32. 2

Hco3- 25.5

Na- 128

K-2. 5

Ca-0. 43

Cl-91



Lft-

Total bilirubin-0. 80

Direct-0. 19

Ast- 36

Alt-33

Alp-404

T. Proteins-5. 8

Albumin-3. 19

A/G -1.22

Chest xray AP view



Chest xray PA view-





A-



Diagnosis -  Severe Anemia( Microcytic Hypochromic)   secondary to ? IDA ? MDS Cardiogenic pulmonary edema ( resolving) (secondary to Heart failure with preserved ejection fraction Ef-62% Renal AKI on CKD stage 3b ? .

 K/c/o type 2 DM since 6 years on tablet metformin 500 mg po/od, 

HTN since 8 years on tab. Metoprolol 25 mg po/od



P-



Inj. Lasix 40 mg iv bd 

Tab. Ecospirin Av 78/10 mg OD HS

Tab. Clinidipine 10 mg /bd

Tab. Pantop 40 mg po/0d

Syp. Cremaffin 20 ml po/hs

Nebulisation with ipravent 12 th hourly

Budecort 12 th hourly

O supplementation to maintain spo2- >94 %

MONITOR VITALS AND INFORM SOS

BP monitoring 4 th hourly

Grbs- 7 point profile 


24/2/23 

ICU BED NO-2

UNIT-2

DOA-21/2/23



80 year old male came with the complaints of shortness of breath since 15 days

B/ l pedal edema and facial puffiness since 3 days

Burning micturition and decreased urine output since 2 days



S-

No fever spikes yesterday

Stools not passed



O-

Patient is conscious, coherent, cooperative

Vitals- 



Temp-98.2F

PR -80 bpm

RR -22cpm

Bp-140/80 mmhg

Spo2- 98% at 1 lit of O2

Grbs- 109mg/dl 

Input- 800

Output -1300

 On 21/2/23



8pm- 137 mg/dl

2am-137 mg/dl



On 22/2/23

8 am - 114 mg/dl

2pm- 135 mg/dl inj. Hai 4 u given 

8pm- 72 mg/dl

On 23/2/23

2 am - 125 mg/dl

8 am- 93 mg/dl inj. Hai 4 u given

2pm- 106 mg/dl inj Hai 4 u given

10 pm- 274 mg/dl

24/2/23

2am- 235 mg/dl

6 am - 69 mg/dl



CVS - S1,S2 present

No murmurs

Jvp - not raised

RS- BAE+, NVBS

P/A - soft, non tender, tympanic note present 

CNS- 

GCS-E4V5M6

Reflexes- Right.     Left

Biceps.       2+.          2+

Triceps.      1+.          1+

Supinator.    1+.        1+

Knee.            2+.         2+

Ankle.           1+.          1+



Investigations -

Hb-7.5 g/dl

Tlc- 12800

Neu-75

Lymp-20

Pcv- 26.2

PLC- 3.6



BGT- O POSITIVE



S electrolytes-



Na- 143

K-3. 1

Cl-99

Ca2+- 1.06



B. UREA-38

S creat-1. 5

Chest xray PA view-




A-



Diagnosis -  Severe Anemia( Microcytic Hypochromic)   secondary to ? IDA ? MDS .Cardiogenic pulmonary edema ( resolving) (secondary to Heart failure with preserved ejection fraction Ef-62% Renal AKI on CKD stage 3b ? .

 K/c/o type 2 DM since 6 years on tablet metformin 500 mg po/od, 

HTN since 8 years on tab. Metoprolol 25 mg po/od

2units PRBC transfusion done



P



Inj. Lasix 40 mg iv bd 

Tab. Ecospirin Av 75/20 mg OD HS

Tab. Clinidipine 10 mg /bd

Tab. Pantop 40 mg po/0d/bbf

Syp. Cremaffin 20 ml po/bd

Nebulisation with ipravent 12 th hourly

Budecort 12 th hourly

O supplementation to maintain spo2- >92%

MONITOR VITALS AND INFORM SOS

BP monitoring 4 th hourly

Grbs- 7 point profile 



25/2/23 

AMC BED NO-5

UNIT-2

DOA-21/2/23

80years old male came with the complaints of shortness of breath since 15 days

B/ l pedal edema and facial puffiness since 3 days

Burning micturition and decreased urine output since 2 days

S-

No fever spikes yesterday

Stools not passed



O-

Patient is conscious, coherent, cooperative

Vitals- 

Temp-98.F

PR -72 bpm

RR -24 cpm

Bp-150/80 mmhg

Spo2- 98% at 1 lit of O2

Grbs- 75mg/dl 

Input- 800

Output -1300

 On 21/2/23

8pm- 137 mg/dl

2am-137 mg/dl

On 22/2/23

8 am - 114 mg/dl

2pm- 135 mg/dl inj. Hai 4 u given 

8pm- 72 mg/dl

On 23/2/23

2 am - 125 mg/dl

8 am- 93 mg/dl inj. Hai 4 u given

2pm- 106 mg/dl inj Hai 4 u given

10 pm- 274 mg/dl

24/2/23

2am- 235 mg/dl

6 am - 69 mg/dl

8am-109mg/dl

2pm- 195 mg/dl

8pm- 103 mg/dl inj. Hai 4 units given

25/2/23

12am- 226 mg/dl

2am- 394 mg/dl

8 am- 75 mg/dl

CVS - S1,S2 present

No murmurs

Jvp - not raised

RS- BAE+, NVBS

P/A - soft, non tender, tympanic note present 

CNS- 

GCS-E4V5M6

Reflexes- Right.     Left

Biceps.       2+.          2+

Triceps.      1+.          1+

Supinator.    1+.        1+

Knee.            2+.         2+

Ankle.           1+.          1+

Investigations -

Hb-8.1 g/dl

Tlc- 17100

Neu-74

Lymp-15

Pcv- 28.7

PLC- 4.1

BGT- O POSITIVE

S electrolytes-

Na- 137

K-3. 1

Cl-95

Ca2+- 0.96

B. UREA-37

S creat-1. 4

A-

Diagnosis -  Severe Anemia( Microcytic Hypochromic)   secondary to ? IDA ? MDS .Cardiogenic pulmonary edema ( resolving) (secondary to Heart failure with preserved ejection fraction Ef-62% Renal AKI on CKD stage 3b ? .

 K/c/o type 2 DM since 6 years on tablet metformin 500 mg po/od, 

HTN since 8 years on tab. Metoprolol 25 mg po/od

C/o sob decreased 

2units PRBC transfusion done

P

Inj. Lasix 40 mg iv bd 

Inj. Hai s/c tid according to grbs

Tab. Ecospirin Av 75/20 mg OD HS

Tab. Clinidipine 10 mg /bd

Tab. Pantop 40 mg po/0d/bbf

Tab. Augmentin 625 mg po/tid

Syp. Potkior 10 ml po /tid

Syp. Cremaffin 20 ml po/bd

Nebulisation with ipravent 12 th hourly

Budecort 12 th hourly

O supplementation to maintain spo2- >92%

MONITOR VITALS AND INFORM SOS

BP monitoring 4 th hourly

Grbs- 7 point profile 

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