86 yr old male with DCMP secondary to IHD with MAT, with COPD .
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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.
A 86 YEAR OLD MALE PATIENT CAME TO CASUALTY ON 18/10/21
▪️ c/o shortness of breath ( grade 4) acc to NYHA classification since 4 days
▪️ c/o orthopnea since 4 days
▪️ c/o fever since 1 day
Patient was apparently assymptomatic 11 years back then he had a prick to his left foot and developed swelling and was taken to RMP and told he has infection and was brought to our hospital which was diagnosed with non healing ulcer after 1 week he was taken to Hyderabad for further evaluation and grafting was done and which was not successful and he got dressing regularly for next 6 months .
And for the next 6 years he didn't have any complaints, ulcer was healing acc to the attender .
2 years back patient had shortness of breath ( grade 4 ) associated with orthopnea ,was taken to Osmania hospital and was diagnosed with HFrEF with EF35% and was put on INJ LASIX and regular dressings was done for the next 2 years.
From 4 days patient had not taken his regular medication
Not a K/C/O DM ,HTN ,ASTHMA, EPILEPSY
K/C/O COPD
Patient is a chronic smoker ( 5 cigarettes/ day or more )
and he stopped smoking since 10 years.
O/E :
pallor present
No Icterus,
No cyanosis,
No clubbing,lymphaedonopathy,oedema
Vitals :
Temp-afebrile
PR-130bpm
RR-29 fpm
BP-110/60 MMHG
SPO2-97 @ ROOM AIR
GRBS - 149 mg/dl
CVS:
S1S2 HEARD
JVP RAISED
APEX BEAT,6th intercostal space at mcl
RS:
B/L INSPIRATORY CREPTS IN ISA,IAA
B/L EXPIRATORY WHEEZE IN IAA,ISA
P/A:
SOFT,NON TENDER
Bowel sounds +
CNS: NAD
CLINICAL IMAGES :
Provisional diagnosis:
HFrEF with EF 45% with COPD with Non healing ulcer of left foot
INVESTIGATIONS :
On 18/10/21 :
ECG :
On 19/10/21 :
Rtpcr negative
On 20/10/21
Serology negative
ECG :
APTT 33 sec
INR 1.11
PT 16 sec
CXR :
On 22/10/21
PT 15 sec
INR 1.11
ECG
TREATMENT GIVEN :
1.)Head end elevation upto 30°
2.)Fuild restriction upto 1 lit / day
3.)Salt restriction < 2.5 g/ day
4.)Inj Neomol 100 ML IV / if temp > 101° F
5.)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 1.25 mg / po/od
8.)Inj Hydrocortisone 100 mg / iv stat
9.)Inj lasix 10 ampules ( 200 mg ) in 30 ml NS at 2 ml / hr
10.)Dressing for Left LL ulcer
11) Moniter vitals
SOAP NOTES :
AMC Bed 1
Unit I admission
SOAP notes Day 2
19/9/21
S : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt is symptomatically improved
O/E
Pallor +
JVP +
PR 130 bpm
BP 100/70 mmHg
RR 28 cpm
Temp 98.6 F
CVS :
JVP elevated
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
B/L INSPIRATORY CREPTS IN ISA,IAA
B/L EXPIRATORY WHEEZE IN IAA,ISA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD
A:
HFrEF with EF 45% secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
With MAT ( Multifocal Atrial Tachycardia )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
5)Inj Lasix infusion @ 1ml/hr
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 1.25 mg / po/bd
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
INJ lasix infusion 10 ampules in 30 ml NS
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj hydrocort 100 mg / IV /TID
SOAP notes Day 3
20/10/21
Fever chart :
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt has tachycardia
O/E
Pallor +
PR 105 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.6 F
CVS :
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
B/L INSPIRATORY CREPTS IN ISA,IAA
B/L EXPIRATORY WHEEZE IN IAA,ISA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj hydrocort 100 mg / IV /TID
Plan Any rate control agents to be added as patient is experiacing sob whenever he is having tachycardia(mat) adequate bronchodialtors are given
SOAP notes
DAY 4
21/10/21
Fever chart :
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
Pt has tachycardia
O/E
Pallor +
PR 90 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.4 F
GRBS 170 mg/dl
CVS :
Jvp increased
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
NVBS +
COARSE CREPTS IN B/L ISA,IAA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Tab Dolo 650 mg PO /SOS
9)Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
10.)Dressing for Left LL ulcer
11) Moniter vitals
12) Strict I/o charting
13) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj lasix 40 mg iv/bd
SOAP notes
DAY 5
22/10/21
Fever chart :
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
O/E
Pallor +
PR 80 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.4 F
GRBS 123 mg/dl
Weight 43 kgs
CVS :
Jvp +
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
NVBS +
COARSE CREPTS IN B/L ISA,IAA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
9) Dressing for Left LL ulcer
10) Moniter vitals
11) Strict I/o charting
12) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj lasix 40 mg iv/bd
SOAP NOTES
DAY 6
23/10/21
FEVER CHART :
S: : decrease in SOB
No fever episode .
O : Pt is conscious ,coherent, cooperative
O/E
Pallor +
PR 65 bpm
BP 110/70 mmHg
RR 22 cpm
Temp 98.4 F
GRBS 163 mg/dl
Weight 43 kgs
CVS :
Jvp +
Apex beat in 6 th ICS at MCL
S1 S2 heard
RS :
NVBS +
COARSE CREPTS IN B/L ISA,IAA
P/A :
Soft , non tender
Bowel sounds +
CNS : NAD ,HMF INTACT
A:
DCMP secondary to IHD With MAT ( Multifocal Atrial Tachycardia )
secondary to CAD with COPD with Non healing ulcer of left foot since 10 yrs ( S/p : grafting ? )
P:
1.)Head end elevation upto 30°
2)Oxygen supplementation .Maintain O2 at > 92%
3.)Fuild restriction upto 1 lit / day
4)Salt restriction < 2 g/ day
6.)Inj pantop 40 MG /IV /OD
7.)Tab carvidelol 3.125 mg / po/bd (increased from od to bd)
8 am ......x ......8 pm
8) Nebulisation with ipravent 6 th hrly and budecort 12 th hrly .
9) Dressing for Left LL ulcer
10) Moniter vitals
11) Strict I/o charting
12) Tab Ecosprin AV /PO/ HS .....75/20
x ...........x..........8 pm
14) Inj Clexane 40 mg / sc / od
15) Inj lasix 40 mg iv/bd
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