This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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
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.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER
Chief complaints:
A 80 year old male came to casuality with chief complaints of :
-SOB grade IV and altered sensorium since 3 days
History of presenting illness:
Patient was apparently asymptomatic 5 months back then he developed altered sensorium for which he was treated in our hospital and diagnosed to have uremic encephalopathy due to acute kidney injury caused by lower UTI. He was treated under OP basis.
Then 3 days ago attendees noticed that patient was tachypneic and doing mouth breathing and was taken to local RMP and told to have BP 200/100 and was brought to local hospital with complaints of altered sensorium -not speaking,responding to commands since 3 days. No complaints of fever, seizures,headache,decreased UO,pedal edema.
He was admitted on 2/12/22 in the morning.
He was sedated and intubated and after sometime he went into cardiac arrest and revived with CPR. He was put on inotropes.
After ABG reports was found to have acidosis and underwent dialysis at 5:30 pm.
Past history :
There is a history of similar complaints 1 yr back when he developed altered sensorium and got admitted in our hospital ,diagnosed to have metabolic encephalopathy and got treated for that and discharged after 3 to 4 days.
No history of DM,HTN,ASTHMA,CAD
Personal history:
Diet-mixed
Appetite-decreased
Bowel and bladder -involuntary since 3 days
Sleep- adequate
Addictions- stopped smoking and alcohol 10 yrs back
General phycial examination
The patient was examined in a well lighted room
The patient was unconscious and under sedation thin built and nourished
Pallor - present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals at 4pm
Temperature : 98.6 ° F
BP : 70/50
PR :100 bpm
RR :14 cpm
SpO2 : 98 % with 100 fiO²
GRBS : 113 mg/dl
Systemic examination
Respiratory :
Inspection :
No visible scars and sinuses
Some hypopigmented spots are present
Chest appears bilateral symmetrical and elliptical in shape
Trachea is central in position with endotracheal tube in it
No dilated veins
And is having central line
Palpation : all inspectory findings are confirmed
Apical impulse is felt in 5th intecostal space
On percussion
Dullness is seen in all areas.
Auscultation:
Crepitus heard
Crepts ad heard in IMA, IAA , ISA
CNS
Patient is unconscious
And is on sederion at 4 pm
And at the time of admission CNS findings
GCS : E2V1M1 ( 4/15 )
Pupils : b/l nsrl
Tone : normal in all 4 limbs
Power : not elisitable
Reflexes :
(R). (L)
Biceps 1+. 1+
Triceps 2+. 1+
Supinator 1+. -
Knee 1+. 2+
Ankle 1+. 1+
Plantar Mute Flexion
Abdomen :
On inspection
Shape : scaphoid
Umbilicus : central , inverted
Equal movements in all quadrants with desperation
Visible pulsations seen under xiphoid sternum
No scars and sinus
No localized swellings
On palpation
No masses palpated
No organomegaly
On percussion
Tympanic note is seen
On auscultation
Bowel sounds are heard
No local lymphadenopathy
Provisional diagnosis: acute pulmonary edema and uremic encephalopathy with chronic renal failure.
INVESTIGATIONS:
At 12:30 pm
Treatment:
Air bed
Inj.Atracurium 5ml/hr(undiluted)
Inj.Medazolam 5ml/he
Inj NORAD 15 ml/ hr acc to MAP
RT feeds 100ml milk + protein powder 4th hrly,200 mo free water 4th hrly
Inj. Pantop 40mg iv OD
Tab.NODOSIS 500 mg RT/TID
Tab. Shelcal RT/OD
Cap bio D3 RT OD weekly once
Inj lasix20mg iv BD
GRBS 4th hrly monitoring
Inj NaHCO3 100 mg +100 ml NS
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