CASE 4: RTR CLINICS-3RD YEAR -sept.

2021

De luna, Blesilda 65/F

In for 2 weeks loss of appetite, easy fatigability 5 days productive cough.

Persistence of cough now with dyspnea prompted consult and admitted at Catbalogan Doctors.
Transfusion was done with noted increasing dyspnea hence she was advised HD refused then
discharged patient came at our ER diuresis was done by DEM then referred to our service.

See at the ER: (+) dyspnea (+) sitting orthopnea (+) occasional cough (-) fever, no uremic signs

BP: 130/70mmHg
HR: 88bpm
O2 Sat: 87%
RA: 99% at 5 LPM NC
Bilateral rales
No edema
UO 1.7 cc/kg/hr

Available labs:

CBC: Hgb 114L

Hct .34L
WBC 10.81L
N .91H
L .16
M .03
E .0
B .0
Platelet count: 357

Creatinine 464.49 H
eGFR 7.9
Ferritin 1903.2 H
LDH 686 H
AST 40H
ALT 86.48 H
HBSag NONREACTIVE

Baseline CXR - bilateral pneumonia cardiomegaly

SALIENT FEATURES:
Demographics
65 years old
Female

HPI Findings
- 2 weeks loss of appetite
- Easy fatigability
- 5 days productive cough (persistent)
- Transfusion was done with noted increasing dyspnea
- Advised for HD but refused
- Diuresis was done by DEM
- (+) dyspnea
- (+) sitting orthopnea
- (+) occasional cough

PE Findings
- BP: 130/70mmHg
- HR: 88bpm
- O2 Sat: 87%
- RA: 99% at 5 LPM NC
- Bilateral rales
- No edema
- UO 1.7 cc/kg/hr

Laboratory Findings
- CBC:
Hgb 114L
Hct .34L
WBC 10.81L
N .91H
Platelet count: 357

Creatinine 464.49 H
eGFR 7.9
Ferritin 1903.2 H
LDH 686 H
AST 40H
ALT 86.48 H
HBSag NONREACTIVE
Baseline CXR - bilateral pneumonia cardiomegaly

Admitting Impression
DIFFERENTIAL DIAGNOSIS
COVID-19
COPD
Chronic Kidney Disease
Congestive Heart Failure