August 24, 2021

60 YEAR OLD FEMALE WITH CHEST PAIN 

60 year old female with chest pain.

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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. 

On 20-08-2021

 

On 21-08-2021

 

 

On 22-08-2021

On 24-08-2021

On 25-08-2021

X ray-

On 21-08-2021

On 25-08-2021

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 1gm /iv/sos if temp >101F

Tepid sponging,ice packs,temp charting 4th hourly 

O2 inhalation if required to maintain spO2 >92%

Tab Telma 40mg/po/od

Tab clopitab 75mg/po/od

Tab ecospirin 75mg/po/od

Tab atorvas 20mg/po/h/s

Bp charting 2nd hourly 

I/O charting 

PR/spo2/grbs charting 6th hourly 

Tab METXL 50mg /po/od

Neb with budecort mucomist @12th hourly 

Inj Lasix 20mgIV STAT

Day 2:-

O2 inhalation if required to maintain spo2 >92%

Tepid sponging,temp charting 4th hourly 

Inj ceftriaxone 1gm/iv/bd(day 2)

Inj pantop 40mg/iv/od

Tab metxl 50mg/po/od

Tab Telma 40mg/po/od

Tab ecospirin 75mg/po/od

Tab clopidogrel 75mg/po/od

Tab atorvas 20mg/po/h/s

Tab pcm 500mg/po/tid

Inj neomol 1gm/iv/sos if temp >101F

Neb with budecort mucomist @12th hourly 

Thrombophobe ointment for L/A

Tab metxl 25mg/po/h/s

Tab thyronorm 25mcg/po/od

Bp charting 2nd hourly 

I/O charting 

PR/spo2/grbs charting 6th hourly 

Day 3:-

O2 inhalation if required to maintain spo2 >92%

Tepid sponging,temp charting 4th hourly 

Inj ceftriaxone 1gm/iv/bd(day 3)

Inj pantop 40mg/iv/od

Tab metxl 50mg/po/od

Tab Telma 40mg/po/od

Tab ecospirin 75mg/po/od

Tab clopidogrel 75mg/po/od

Tab atorvas 20mg/po/h/s

Tab pcm 500mg/po/tid

Inj neomol 1gm/iv/sos if temp >101F

Neb with budecort mucomist @12th hourly 

Thrombophobe ointment 

Tab metxl 25mg/po/h/s

Tab thyronorm 25mcg/po/od

Syp ambroxol po/tid

Day 4:-

O2 inhalation if required to maintain spo2 >92%

Tepid sponging,temp charting 4th hourly 

Inj ceftriaxone 1gm/iv/bd(day 4)

Inj pantop 40mg/iv/od

Tab metxl 50mg/po/od

Tab Telma 40mg/po/od

Tab ecospirin 75mg/po/od

Tab clopidogrel 75mg/po/od

Tab atorvas 20mg/po/h/s

Tab pcm 500mg/po/tid

Inj neomol 1gm/iv/sos if temp >101F

Neb with budecort mucomist @12th hourly 

Thrombophobe ointment 

Tab metxl 25mg/po/h/s

Tab thyronorm 25mcg/po/od

Syp ambroxol po/tid

Day 5:-

O2 inhalation if required to maintain spo2 >92%

Tepid sponging,temp charting 4th hourly 

Inj ceftriaxone 1gm/iv/bd(day 5)

Inj pantop 40mg/iv/od

Tab metxl 50mg/po/od

Tab Telma 40mg/po/od

Tab ecospirin 75mg/po/od

Tab clopidogrel 75mg/po/od

Tab atorvas 20mg/po/h/s

Tab pcm 500mg/po/tid

Inj neomol 1gm/iv/sos if temp >101F

Neb with budecort mucomist @12th hourly 

Thrombophobe ointment 

Tab metxl 25mg/po/h/s

Tab thyronorm 25mcg/po/od

Syp ambroxyl po/tid

Syp mucaine gel 2tablespoons/po/bd

Inj clexane 40mg sc/od (day 1)

Day 6:-

O2 inhalation if required to maintain spo2 >92%

Tepid sponging,temp charting 4th hourly 

Inj ceftriaxone 1gm/iv/bd(day 5)

Tab pantop 40mg/po/od

Tab metxl 50mg/po/od

Tab Telma 40mg/po/od

Tab ecospirin 75mg/po/od

Tab clopidogrel 75mg/po/od

Tab atorvas 20mg/po/h/s

Tab pcm 500mg/po/tid

Inj neomol 1gm/iv/sos if temp >101F

Neb with budecort mucomist @12th hourly 

Thrombophobe ointment 

Tab metxl 50mg/po/h/s

Tab thyronorm 25mcg/po/od

Syp ambroxyl po/tid

Syp mucaine gel 2tablespoons/po/bd

Inj clexane 40mg sc/od(day 2)