CHETANA KETA ROLL NO. 74: August 2022

Friday 26 August 2022

70 yr old male with acute loss of speech and left upper and lower limb weakness

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 70 year old male, resident of Chinakaparthy, Nalgonda district came to OPD with chief complaints of:

- Generalised weakness since 20 days

- Loss of speech and unable to move his left upper and lower limbs since morning on 25th August.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 7 months back,then in Jan,2022 he developed stomach pain and swelling in the legs and got checked up in Nalgonda and diagnosed to have grade 1 fatty liver, GB sludge with calculi and mild right hydroureteronephrosis.

There is a history of decreased bladder control since 20 days.

There is no history of palpitations,chestpain,breathlessness, fever,nausea and vomiting.

PAST HISTORY:

No similar complaints in past.

He is known case of diabetes and Hypertension since one year and was on regular medication.

No H/o Tuberculosis, Epilepsy,Asthma.

PERSONAL HISTORY:

Diet - Mixed

Appetite -Normal

Bowel and bladder -Regular.

Sleep - Adequate

Addictions: consumes Alcohol since 40 years and Smoker consumes 3 to 4 biddi per day.

FAMILY HISTORY:

No signicant Family history

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative

He is moderately built and nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent

Clubbing -present

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission

Temperature - Afebrile

Pulse rate - 103 bpm

Respiratory rate - 16 cpm

BP- 180/90 mmHg

SpO2 - 96% on Room air

GRBS - 160mg/dl

SYSTEMIC EXAMINATION:

CNS Examination:

Face is turned towards Right side.

-Loss of speech

Cranial nerves :

CN 7- nasolabial fold on left side is less prominent. Deviation of mouth to Right side. Forehead wrinkles are absent on left side.

CN 11-Sternocleidomastod muscle spasm on right side.

Other cranial nerves are normal.

ATTITUDE:

Left upper limb - flexed and pronated

Left lower limb - externally rotated

BULK of the muscles - Normal

POWER : Right Left

Upper Limb 4/5 0/5

Lower Limb 5/5 0/5

TONE : RIGHT LEFT

UL NORMAL CLASP KNIFE

LL NORMAL HYPOTONIA

REFLEXES : Right side. Left side.

Biceps Present Absent

Triceps Present Absent.

Supinator Present. Absent.

Knee Present. Absent

Ankle Present. Absent

CVS :S1 ,S2 heard , no murmurs.

RESPIRATORY SYSTEM:BAE Present.

PER ABDOMEN::

Soft and non tender , bowel sounds +

CLINICAL IMAGES:

Investigations:

X RAY

Tuesday 23 August 2022

A 28 year old male - abdominal distension and SOB

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

23-08-2022

A 28 year old male came to OPD with cheif complaints of abdminal distention since 25 days and breathlessness since 5 days

HOPI:

23-08-2022

A 28 year old male came to OPD with chief complaints of

Abdominal distention since 20 days

Shortness of breath since 15 days

History of present illness

Patient was apparently asyptomatic 4 months back then In April he had fever ,yellowish discoloration of eyes for 3 days , fever is not associated with chills and rigor ,no evening rise of temperature he went to hospital , used medication for 1week.

Symptoms subsided after a week ,he started to consume alcohol(180 ml) daily since then .

In the month of June he had Abdominal distension, yellowish decolorisation of sclera , went to a hospital in jangaon took ayurvedic medicine for 1 week , symptoms subsided.

He started to drink alcohol from July 1st till 27 th July .

Then he presented on July 28 with complains of Abdominal distension since 6days, Shortness of Breath Gradelll ,fever not associated with Chills and rigor without evening rise of temperature, Altered sleep cycle,facial puffiness,, pedal edema is seen for 3 days.

On 29/7 Ascitic tap was done.

22-08-2022

The patient came back to OPD with abdominal distention since 20 days that increased on consuming food and decreased on passing stools

The patient also complains of shortness of breath since 15 days even while resting associated with palpitations , giddiness and fearfulness

He developed dry cough since 5 days that relived on medication

He complains a fever episode 2 days ago that relived on medication

Patient has loss of appetite since 2 days due to abdominal tightness

Past history

N/K/C/O DM/HTN/TB/ASTHMA/CAD

PERSONAL HISTORY:

Diet : Mixed

Appetite : Decreased

Sleep : Disturbed

Bowel and Bladder moments : Constipation is seen

Micturition : Normal

FAMILY HISTORY:

Not significant

General physical examination:

Patient is conscious ,coherent and cooperative and well oriented to time, place and person.

moderately built and nourished.

Pallor-absent

Icterus-present

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

Vitals:

Temperature - 98.2*c

PR :- 95bpm

RR :-22cpm

BP :- 130/80mm Hg

SPO2 :- 98%

GRBS :- 167mg/dl.

Systemic examination:

CVS- S1S2 no murmurs

RS-BVS+, wheeze+

P/A-soft

Uniformly distended.

Umbilicus everted.

Engorged veins present.

Investigations:

LFT:

ECG:

USG:

2D ECHO:

X-RAY:

PROVISIONAL DIAGNOSIS:

Chronic liver disease

Treatment:

1. FLUID RESTRICTION.
2. SALT RESTRICTED NORMAL DIET.
3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY.
4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.
5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.
6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY.
7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY.
8. TAB. PCM 650 mg SOS (<1 GRAM / DAY).
9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.

Sunday 21 August 2022

A 68 year old male with pedal edema, palpitations and shortness of breath

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 diagnosis with a treatment plan.

This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.

A 68 year old male patient, resident of Nalgonda who was farmer by occupation came to OPD with chief complaints of:

-swelling of legs since 10 days

-shortness of breath since 10 days

-palpitations since 10 days

-loss of appetite since 10 days

History of presenting illness:

Patient was apparently asymptomatic 10 years back then he had a history of fall and fracture of hip on right side then traction was done.

Then pain in the back in loin region started 4 years back in Dec,2019, which was dragging type which temporarily relieved on taking medication. Pedal edema and SOB also started and SOB increased on walking .

Investigations done 4 years back on 2/12/19:

Patient was advised to undergo dialysis and 10 sessions were done in Dec 2019 and Jan 2020. As the status of the patient improved, dialysis sessions were stopped. From Jan 2020 to Feb 2022 patient was alright with no pedal edema or shortness of breath. Then 10 days back he observed pedal edema and also shortness of breath which increased on walking (grade III).

Patient is not complaining of any fever,cough. Urine output is normal. Burning micturition is present since 10 days.

Past history:

Patient is a known case of HYPERTENSION and using medication since 4 years.

No h/o DM,asthma,epilepsy

Personal history:

Diet:mixed

Appetite-decreased

Bowel and bladder movements:regular

Sleep: disturbed

Addictions: occasional toddy and alcohol drinker since 15 yrs old. Heavy beedi smoker( 1 packet in 3 days) since 15 yrs old.

VITALS

Temp- 98.8 F

PR- 94 bpm

BP- 140/80 mmHg

RR- 18 cpm

Spo2- 98% at RA

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative.

No signs of Pallor, Icterus, Cyanosis, Clubbing or lymphadenopathy.

Shortened right leg

SYSTEMIC EXAMINATION

CVS: S1 S2 heard, no murmurs/thrills

RS: BAE+, NVBS heard

PA: Soft, non tender.

CNS: NFND

PROVISIONAL DIAGNOSIS

Renal failure (?Hypertensive Nephropathy)

Investigations on 21/2/22:

Hb: 8.3 mg/dl

Blood Urea: 113 mg/dl

Serum Creatinine: 7.1 mg/dl

USG Abdomen:

- b/l grade 3 RPD with simple renal cortical cysts

- Urinary bladder wall thickened with diverticulae suggestive of chronic cystitis

- evidence of hyperechoic foci in urinary bladder wall likely emphysematous cystitis

Treatment

1. Fluid and Salt restriction

2. Tab Lasix 40 mg PO/BD

3. Tab Nicardia 20 mg PO/BD

4. Inj. ERYTHROPOIETIN 4000IU SC weekly once

A 45 year old female with fever and bl loin pain

This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.

A 45 year old female who is an agriculture labourer by occupation to OPD with chief complaints of:

- fever 15 days back

-bl loin pain-10 days back

- unable to pass urine since 10 days

- altered sensorium 1 week back

History of presenting illness:

Patient was apparently asymptomatic 15 days back,then she developed low grade intermittent fever with no chills and rigors for which she went to local hospital and the reports showed:

-Serum creatinine: 1.8

-Pus cells in urine

-USG abdomen: left hydronephrosis

Fever subsided on taking medication. It was associated with burning micturition.

B/L loin pain was colicky type with no aggravating and relieving factors

On admission, Foley's catheter was passed and pus was noticed.

Patient had slurred speech on the day of admission and couldn't recognise anyone.

Dialysis was done due to abnormal RFT results.

Swelling of upper and lower limbs started to appear since 1 week due to fluids infusion.

Her sensorium improved during course of treatment.

Past history:

History of renal calculi since 1 month.

Not a known case of Diabetes,Hypertension, Coronary Artery Disease,Asthma, Chronic Kidney Disease.

Surgical history:

Hysterectomy done 10 years ago.

Vitals on examination:

Temperature: afebrile

PR: 120 bpm

RR: 16cpm

BP: 110/80 mm Hg

GRBS: 106 mg/dl

CVS: S1,S2 present

RS: BAE +

CNS: Hypertonia of both lower limbs seen.

On examination:

Abdomen is soft and distended.

Midline scar is present.

No guarding or rigidity.

Investigations:

On 8th: On 9th:

Hb: 11.0 mg%. Hb: 10.8 mg%

TLC: 41,000. TLC: 41,600

Platelets: 2.0 lakh. Plt: 1.7 lakh

pH: 7.29

pCO2: 26.2

pO2: 69.6

SO2: 92.2

HCO3: 12.5

S.Creat: 4.2

S. Urea: 153

S. Uric acid: 10.4

S. Ca: 9.4

S.PO4: 3.8

S. Na: 140

S. K: 6.4

S. Cl: 103

LFT:

TB: 4.34

DB: 2.86

AST: 22

ALT: 16

ALP: 679

TP: 4.7

Albumin; 1.8

A/G: 0.62

On 9th:

S. Iron: 84

RBS: 64

HbA1C: 6.4 %

On 10/2/22:

pH: 7.31

pCO2: 31.4

pO2: 90.8

HCO3: 15.4

SO2: 94.3

Hb: 11.1

TLC: 48000

Plt: 1.35

S. Urea: 80

S. Creat: 2.9

S. Na: 141

S. K: 4.8

S. Cl: 101

LFT

TB: 5.28

DB: 4.25

AST: 36

ALT: 17

ALP: 657

TP: 5.1

Alb: 1.9

A/G: 0.5

ECG on 8/2/22:

Shows sinus tachycardia

X ray KUB on 8/2/22:

USG DONE ON 8/2/22:

B/L hydronephrosis

Right simple renal cortical cyst

Grade I fatty liver

NCCT KUB:

Pneumoperitoneum with ?left perinephric abscess.

Air foci in upper calyx of right kidney- ? Emphysematous pyelonephritis

Mild ascitis.

MDCT SCAN BRAIN- PLAIN:

No abnormality in brain.

Treatment given:

On 8/2/22:

Soft diet

IV FLUIDS 1. NS and 1. DNS at 75ml/hr

Inj. MEROPENEM 1g/IV/BD

INJ. PAN 40mg IV BD

INJ. PCM 1g IV BD

INJ TRAMADOL 2amp in 100ml NS IV BD

Monitor vitals

On 9/2/22:

INJ MEROPENEM 1gm IV BD

INJ METROGYL 100ml IV TID

INJ. PCM 1g IV BD

INJ. PAN 40mg IV BD

IV FLUIDS 2. NS AND 2. RL at 100ml/hr

Ryle’s tube feeds (100ml milk and 100ml water) 4th hourly

INJ. NORAD (2amp + 36ml NS)

GRBS 4th hourly monitoring

Strict I/p and O/p monitoring

On 10/2/22:

INJ MEROPENEM 1gm IV BD

INJ METROGYL 100ml IV TID

INJ. PCM 1g IV BD

INJ. PAN 40mg IV BD

IV FLUIDS 3. NS AND 2. RL at 100ml/hr

Ryle’s tube feeds (100ml milk and 100ml water) 4th hourly

INJ. NORAD (2amp + 36ml NS)

GRBS 4th hourly monitoring

Strict I/p and O/p monitoring

INJ HAI S/C TID after informing GRBS

Nephrostomy was done on 10/2/22 at 2:30 PM and 500 ml of pus was drained.

Nephrostomy procedure

On 19/2/22:

INJ MEROPENEM 500 mg IV BD

INJ METROGYL 500mg(100ml) IV TID

INJ PAN 40 mg IV OD

HAI s/c acc to GRBS

INJ TRAMADOL(1 amp 1ml) NS IV BD

INJ NEOMOL 1g IV

GRBS monitoring 6th hrly

BP,PR,SpO2 monitoring 4th hrly

On 20/2/22:

INJ MEROPENEM 500mg IV BD

INJ METROGYL 500mg(100ml) IV TID

INJ PAN 40mg IV OD

INJ HAI s/c after GRBS

INJ TRAMADOL (1 amp 1ml) NS IV BD

INJ NEOMOL 1g IV

GRBS monitoring 6th hrly

BP, SpO2,PR monitoring 4th hrly

PROVISIONAL DIAGNOSIS:

B/L emphysematous pyelonephritis with aki secondary to sepsis

With denovo diabetes mellitus

Discussion:

Emphysematous pyelonephritis refers to a morbid infection with particular gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and, therefore, carries a high mortality.

Clinical presentation

The patient usually presents with fevers and flank pain. In diabetics, who are the ones at risk for this condition, leukocytosis and hyperglycemia are prominent laboratory findings.

Pathology

Etiology

It tends to be more common in females, and approximately 90% of patients have uncontrolled diabetes mellitus 1. It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms, or sloughing of papilla.

Causative organisms include:

Escherichia coli: usually considered the commonest causative organism 3

Klebsiella pneumonia

Proteus mirabilis

65 yr old female - DKA

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect 6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION :

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

A 65 yr old female, housewife and a resident of Narketpally complaints of fever associated with chills and rigors 10 days back for 4 days for which she went to a local RMP and diagnosed to have elevated sugar levels and was referred and got admitted in our hospital.

HOPI:

Patient was apparently asymptomatic 20 yrs back,then she got fever and underwent some tests and diagnosed to have hyperthyroidism for which she is using Neocarbimazole 5mg PO OD

10 years ago she had fever and decreased appetite for which she went to a local hospital and diagnosed to be type 2 DM and kept on OHA

10 days back she had high grade fever associated with chills and rigors for about 4 days ,she also had decreased appetite and stopped taking OHA

She developed breathlessness since 10 days

Difficulty in walking and weakness of lower limbs present

She passed urine and stools in her clothes.

Past history :

Diabetic since 10 years on Insulin

Hyperthyroidism since 20 years on neocarbimazole 5mg Po OD

Asthma since 20 years .

PERSONAL HISTORY

DIET mixed

APETITE decreased