159 Ravali Irugurala

        General medicine

                                                    
                                                          21/0ct/ 2021

 Name : Ravali Irugurala 

 Roll no : 159 

3rd sem student

 This is an online e log book to discuss our patient de- identified health data shared after taking his/ her guardians signed and informed consent.

 I've 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 a diagnosis and treatment plan.

Case presentation:

A 74 yr old male , retired RTC driver(11 yrs back) , resident of narketpally came to the casuality with complaints of fever since 3 days , decreased urine output since 2 days,SOB GRADE :3 since 1 day.
  
History of present illness:

1.FEVER:
- Sudden in onset, associated with chills, increased during nights &  relieved on medications.fever spikes increased after connecting urine bag before 2 days

2.DECREASED URINE OUTPUT:
- Normal frequency was 4 times/day & 3 times/night.since 2 days from tuesday morning, output decreased.they went to local RMP at night 10pm of tuesday  & urine bag was connected by local RMP.

3.SOB GRADE : 3 
- Present while walking & at rest also

Past History:

Pt was apparently asymptomatic 2 months back, was admitted & diagnosed in our hospital with Lft  facial nerve palsy, peripheral neuropathy(? ATT INDUCED), denovo HTN (? post pulmo tb), Spondyloarthropathy  with radiculopathy sacroileitis cervical OPLL ( Ossification of posterior longitudinal ligament) - Ankylosing spondylitis
- k/c/o DM - 2 Since 20 yrs.

Personal History:

DIET: vegetarian 
APPETITE : decreased since 1 month
SLEEP: decreased since 2 days
BOWEL & BLADDER MOVEMENTS : urine  decreased
ADDICTIONS : smoking present since 20 yrs ( 3 packets/day ) stopped 5 yrs back

VITALS: 

Temperature: febril

PR: 98 bpm

RR:22 Cp

BP : not recordable

Spo2: 98%


General examination:

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,pedal edema

Systemic examination:

CNS: FNAD

CVS: S1 &S2 heard ,no murmurs

Respiratory system: NVBS
 
PERABDOMEN:
Soft , tenderness & pain present
Abdominal distension: present
  
Investigations:

Chest x ray:






2 D echo report:




ABG report:




Liver function test:



Serum electrolytes:



Blood urea:




Serum creatinine:





 
PROVISIONAL DIAGNOSIS:

AkI (pre renal / renal ) on CKD k/c/o HTN /DM cervical myelopathy.altered sensorium secondary to metabolic (? Hepatic/ uremia)

TREATMENT:

On  21/010/21

•INJ.PIPTAZ 2.25/ IV / TID

•INJ.PAN 50 mg /IV/OD

•INJ.ZOFER 4mg /IV/SOS

•INJ.PCM.1gm /IV/SOS

•INJ.NOR-ADREANALINE 10ml/hr   NS


            
Patient suddenly became unresponsive at today 7:00 pm with no cardiac activity
CPR was initiated acc to 2015 AHA guidelines and intubated with ET 7.0 ROSC obtained after 5 cycles of CPR and patient was put on mechanical ventilator

ACMV-VC
Fio2: 100
RR: 14 cpm
VT: 420ml
PEEP: 5cms

Post intubation vitals:
PR: 110 bpm
BP: 70/40 mmhg
Spo2: 98%
CVS: s1 s2 + 
RS: BAE + , NVBS
P/A: Soft , BS +

ECG report:

ECG report after 1 hr:



At 1:35 AM on 22/10/21 patient again became unresponsive with no cardiac activity
CPR initiated acc to 2015 AHA guidelines and continued for 6 cycles.
Inspite of all the resuscitative measures patient could not be revived and declared dead at 2:05 AM on 22/10/21


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