CH. Preethi
Roll number- 19
4th year MBBS
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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
A 80 year old female came to casualty with complaints of:
-shortness of breath since 2days
-generalised weakness since 2days and
-chest pain since 1day
History of presenting illness:
-Patient was apparently asymptomatic 3years ago then she developed giddiness for which she was diagnosed as hypertensive and used medications (Amlodipine 5mg, atenolol 50mg).
-Patient has generalised weakness which was associated with SOB (grade 2)
-Next day around 2pm, she developed shortness of breath which is grade 4(while at rest) for which she went to local hospital and used medications and her symptoms subsided. At around 8pm again she developed SOB (grade IV)which was associated with chest pain for which she was reffered to our hospital
Patients spo2 was 40 and was intubated at below settings.
After intubation patient went into cardiac arrest, she had a weak pulse and blood pressure was non recordable. Then 3 cycles of cpr was done along with adrenaline (1ml per each cycle of cpr).
Past history:
She's is a known case of hypertension and is on medication since 3years
Vitals on admission:
PR: 90bpm
BP: 90/60 mm hg@norad6ml/hr, dobutamine 5ml/hr)
SpO2: 40% on RA
Cvs-s1s2 +
Rs-BAE+
P/a- soft
On examination:
Mild pallor present.
No icterus, cyanosis, clubbing, lymphadenopathy.
25.3.22
Post intubation ECG:
ECG on 26/03/22
ABG on 25.3.22
ABG on 26.3.22
Chest X ray:
RBS,RFT,LFT, Tropinin I
Diagnosis:
? Unstable angina
?acute exacerbation of copd
Treatment
Day 1
1) inj.norad - 2amp in 46ml ns @6ml/hr.
2) inj dobutamine - 1amp in 45ml ns @5ml/hr
3) inj.Clexane - 60mg/sc/bd
4) tab.ecospirin 325/RT/stat
5) tab.clopidogrel 200mg/rt/stat
6) tab.atorvastatin 80mg/rt/stat
7) bp monitoring hrly
8)inj.NaHCo3 50mg/iv/stat
Day 2
1) Rt feeds 100ml milk and 10ml water @4th hrly
2) inj.augmentin 1.2gm/iv/bd
3) inj.norad - 2amp in 50ml ns @20ml/hr.
4) inj dobutamine - 1amp in 50ml ns @5ml/hr
5) inj.vasopressin (1amp + 50ml NS) IV @2ml/hr
6) inj.heparin 5000IU /IV/QID
7) tab.ecospirin 150mg/RT/stat
8) tab.clopidogrel 200mg/rt/stat
9) tab.atorvastatin 40mg/rt/OD
10) Nebulisation with budecort and mucomist @8th hrly
11) vitals monitoring hrly
12) frequent post change every hrly
13) arterial and central line every 4th hrly
14) strict I/o charting
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