75 year old female with type 2 DM WITH NSTEMI with acute exacerbation of asthma.

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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.

VISHAL SARDA

ROLL NO:93

UNIT -I

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

THE CONSENT  WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

CASE PRESENTATION:-

Patient was brought to the casualty with complaints of shortness of breath since 10 days and dry cough occasionally.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 10 days back , then developed shortness of breath , which was insidious in onset , MMRC - II, not associated with wheeze, aggravated on exposure to cold and dust , orthopnea + .No PND.

Patient also has complaints of  dry cough since 1 week - occasionally , no aggravating or relieving factors .No h/o fever, chest pain, chest tightness, hemoptysis, sweating and palpitation,loss of weight and loss of appetite.

PAST HISTORY :-

H/o similar complaints since 10 years , on rotahaler ( fluticazone and vilantrol).

Patient is on tab. Acebrophyllin 100mg PO BD

N o h/o TB in the past.

No h/o HTN, CAD, Epilepsy ,thyroid disorders.

PERSONAL HISTORY:

Diet:Mixed.

Apeptite:Decreased

Sleep-adequate.

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-none .

Attained menopause 26 years back.

GENERAL EXAMINATION :-

GENERAL EXAMINATION 

Patient is c/c/c , moderately built and nourished 

No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy.

Bilateral pitting pedal edema present.

VITALS:-

•Temp- 98.6 F

•PR- 98bpm

•BP- 120/80 mmhg 

•RR- 19 cpm

•SpO2- 97% at RA 

•Grbs- 358 mg/dl

SYSTEMIC EXAMINATION :-

RESPIRATORY SYSTEM EXAMINATION -

UPPER RESPIRATORY TRACT -

•Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 

•Dental caries present 

•Nose - No septal deviation or Nasal polyps 

LOWER RESPIRATORY TRACT -

1.INSPECTION :

•Shape of the chest - elliptical 

•There is drooping of shoulder towards left side

•Trachea appears to be central 

•Equal movement of chest wall on both sides

•No usage of  accessory muscles 

•No scars ,sinuses ,engorged veins, edema 

2.PALPATION :

•No local rise of temperature  , no tenderness 

•Trachea central

•Movement of chest wall  equal

•Vocal resonance and tactical fremitus equal on both sides

•Auscultation- Bae present ,nvbs present 

•Coarse crepts present in b/l ica ma isa infra isa iaa.

CVS - s1,s2 heard, no murmurs.

CNS -  no focal neurological deficit.

P/A- soft, non tender , no organomegaly.

INVESTIGATIONS:- 

Culture- no growth.

Sputum - streptococcus pneumonia.

ECG:-

1/12/2023

HEMOGRAM:-

                                   30/11.           1/12.              2/12

Hb-                             #10.7.          #9.6.             #10.6 

TC-                              #13700.       # 15500.      #12700

Neutrophils-            76.                 80.                65

Lymphocytes-          20.                15.                 30

Eosinophils-             2.                  2.                   3

Monocytes-               2                  3.                     2

Basophils-                0.                  0.                   0

Pcv-                           #32.              #27.9.         #31.8

Mcv-                          86.8.             84.7.           86.2

Mch-                           28.4.           29.              28.6

Mchc-                            32.7         34.3.            33.2

Rdw-cv-                    #14.3.         #14.7.          #14.7

Rdw- SD-                  46.6.           47.9.             47.5

RBC-                         #3.6.            #3.3.            #3.7

Platelets-                 1.7.             1.53.             1.9

CHEST XRAY-

2d-echo :-

RFT:-

                               30/11.          1/12.      2/12

Urea-                                         #63.        #58

Cratinine-                                   1.1.        #1.3

Uric acid-                                   3.2.       3.7

Calcium-                                    8.7.        10.1

Phosphorus-                            2.6.          #2.0

Sodium-                 #125.        #131.       #131

Potassium-            #2.8.         #3.2.           3.5

Chloride-               98.            98.             98

GRBS monitoring:-

PROVISIONAL DIAGNOSIS:-

Type 2 diabetes mellitus with CAD - NSTEMI with acute exacerbation of asthma.

TREATMENT:-

•TAB.CEFIXIME 200 MG PO BD

•CAP.FLUCONAZOLE 150 MG PO OD

•TAB.GLIMIPERIDE 1 MG PO OD

•TAB.METFORMIN 500 MG PO BD

•TAB.LASILACTONE 20/50 

•TAB.PREDNISOLONE 20 MG OD.

•TAB.ECOSPIRIN 75 MG OD

•TAB.ROSUVASTATIN 200 MG OD

•TAB.CLOPIDOGREL 75 MG OD

•TAB.MUCINAC 600 MG IN 1 GLASS WATER

•TAB. MONTEK -LC

•TAB.ACEBROPHYLLINE 100 MG BD

•NEBULIZATION WITH IPRAVENT 6TH HRLY AND BUDECORT 12 TH HRLY.

•SYP.GRILLINCTUS 10 ML BD

•SYP. POTKLOR 15 ML IN 1 GLASS WATER 

•TAB. PANTOCID 40 MG PO BEFORE FOOD .