1801006074 - SHORT CASE

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 50 year old man, resident of Nalgonda came to OPD on 16/3/23 morning with chief complaints of pain abdomen since 6hrs.

History of presenting illness:

        He developed pain abdomen at 12 am on 15/3/23 which was sudden in onset and gradually progressive. Pain was diffusely present but more in umbilical and left lumbar region. It was colicky type and non radiating. Pain was continuous with no aggravating and relieving factors.

History of alcohol intake present.

No history of fever,nausea,vomiting or loose stools.

Past history:

Similar complaints in the past 2 years back and was diagnosed to have acute pancreatitis.

He is a known case of diabetes since 2 years and was on medication(?)

No history of Hypertension, Asthma,Tuberculosis, CAD.

Personal history:

Daily routine:

He wakes up at 8 am and does his daily routine and is not working ,takes 3 meals daily and drinks alcohol and smokes intermittently through the day and sleeps by  10 pm.

           Diet- mixed

           Appetite- normal

           Bowel and bladder movements- regular

           Sleep- disturbed since 2 days

           Addictions- chronic alcoholic since 30                                  years(takes about 180 ml                                    per day on average)

                                Smokes cigarettes 2-3                                        packs per day since 30                                        years

Family history:insignificant

General examination:

Patient is conscious,coherent and cooperative ,moderately built and nourished.

Pallor:absent

Icterus:absent

Cyanosis:absent

Clubbing:present

Lymphadenopathy:absent

Edema:absent

Vitals:

Blood pressure: 150/100 mm Hg

Pulse rate:65bpm

Respiratory rate:20 com

Temperature:afebrile

Systemic examination:

Per abdomen examination:

On inspection: abdomen is obese,umbilicus is central and inverted. All quadrants of abdomen are moving accordingly with respiration. No visible scars,sinuses,engorged veins.

On palpation: all inspectory findings are confirmed, abdomen is soft and tenderness is present in the umbilical and left lumbar lumbar region. No guarding or rigidity . No hepatospleenomegaly and hernial orifices are free.

On percussion: no shifting dullness

On auscultation: bowel sounds heard

CVS: S1,S2 heard,no murmurs

Respiratory system: bilateral air entry present,normal vesicular breath sounds heard

CNS: no neurological deficit.

Provisional diagnosis: 

Acute on chronic pancreatitis secondary to alcohol intake.

Investigations:

Hemogram:

Hb 16.2 mg/dl 

Total count 9,300 cells/cumm

Neutrophils  82%

Lymphocytes 10 %

MCV 91.9

MCH 32.5

MCHC 35.5

RBC count 4.96 millions/cumm

Smear:

Normocytic,normochromic-RBC

WBC within normal limits with neutrophils

Platelets- adequate

 Serum Lipase: 230 IU/L

Serum Amylase: 471 IU/L

RBS: 246 mg/dl

LFT:

Total bilirubin :1.25 mg/dl

Direct bilirubin  0.52 mg/dl

SGOT: 32 IU/L

SGPT: 41 IU/L

Alkaline phosphatase : 322 IU/L

Total proteins 7.7 gm/ dl

Albumin : 4.45 gm/dl

Serum creatinine: 1.3 mg/dl

CUE: 

Pale yellow,clear,acidic 

Sp gravity: 1.010

Albumin ++

Sugar +

Bile salts nil

Bile pigments nil

Pus cells 4-5 /HPF

RBC nil

Casts nil

USG:

Grade  I fatty liver

Left kidney not visualized in left renal fossa

CT:

Pancreas:

Bulky with heterogeneous parenchymal enhancement with peripancreatic fat stranding associated with fluid traversing along left paracolic gutter.

No parenchymal necrosis.

No peripancreatic collection or pseudo cyst

Splenic artery patent

Minimal ascites.

Spleen normal

Liver ,gall bladder normal

Impression: features suggestive of acute interstitial pancreatitis with modified CT severity score of 4. Minimal ascites

Treatment:

-NBM 

-  IV fluids : NS and RL ( 100ml/hr) 

-Inj pantop 40mg IV OD 

-Inj Thiamine 200mg in 100ml NS iv tid 

- Inj HAI s/c tid premeal. 

- BP, PR, RR, temperature monitoring and charting 4th hourly.

1801006074- Long Case

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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 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. 

Chief complaints:

             A 50 year old male, resident of Nalgonda ,who works in an ice factory came with complaints of:

            - weakness of right upper and lower                     limbs since 5 days

            - slurred speech since 5 days.

History of presenting illness:

              Patient was apparently asymptomatic 1 month back, then he developed weakness in left upper and lower limbs which was sudden in onset and was taken to local hospital when he was diagnosed to have hypertension and his condition improved with medication in about 3 days.

             He took medication for 20 days and stopped for next 10 days when he developed sudden onset of weakness in right upper and lower limbs (which was 5 days ago). He also developed slurred speech and was taken to local hospital and then was referred to our hospital next day.

             There is no history of loss of consciousness, altered sensorium,fever,headache,vomiting,seizures,behavioural abnormalities or abnormal movements.

 

Past history:

He is a known case of hypertension since 1 month.

There is no history of diabetes, asthma,TB,epilepsy,coronary artery disease or thyroid abnormalities.

Personal history:

The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He takes mixed- diet.He finishes work by around 6:00 pm, comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm. 

The patient has history of chewing tobacco for around 10 years.

He consumes alcohol regulary since 30 years. He stopped for around 3 years and started again 6 months ago.

Bowel and bladder movements-regular.

Treatment history:

He took medication for hypertension- Amlodipine and Atenolol for 20 days and stopped for the past 15 days.

Family history:

No history of similar complaints in the family.

General examination:

Patient is conscious and cooperative. 

He is well oriented to time,place and person.

Moderately built and nourished. 

Vitals :- 

Temp - afebrile

BP  - 140/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

SYSTEMIC EXAMINATION:

CNS EXAMINATION:

Right handed person.

Higher mental functions are intact.

Speech- slurred

Behaviour-normal

Memory- intact

Intelligence-normal

No hallucinations or delusions

Gait:

CRANIAL NERVE EXAMINATION:

I - no alteration in smell

II -

Visual acuity- normal

Field of vision- normal 

Color vision - normal

III, IV, VI -

EOM- normal

Diplopia- absent

Nystagmus absent

No ptosis

V - sensations of face normal, can chew food normally 

VII - Deviation of mouth to the left side, upper half of right side and left side normal

Taste sensation over anterior 2/3 of tongue present

VIII - hearing is normal, no vertigo or nystagmus 

IX,X - no difficulty in swallowing 

XI - neck can move in all directions 

XII - tongue movements normal, no deviation

Pupils - both are normal in size, reactive to light 

Motor examination:

Tone:

RUL: increased

LUL: normal

RLL: increased

LLL: normal

Power:

RUL: 3/5

LUL: 4/5

RLL: 3/5

LLL: 4/5

Reflexes: 

Superficial reflexes:

                          Right               Left

Corneal :         present          present

Conjunctival:  present          present

Abdominal:     present  in all quadrants

Plantar :          not elicited     flexion

Deep tendon reflexes:

                            Right                 Left

Biceps                  ++                     ++

Triceps                 ++                     ++

Supinator             ++                     ++

Knee jerk             +++                   ++

Ankle jerk            +++                   ++

Sensory examination:

Pain, temperature, crude touch, pressure sensations- normal

Fine touch, vibration, proprioception- normal

No abnormal sensory symptoms .

Tactile localisation- able to localise

Cerebellar examination:

Finger nose test- normal

No dysdiadochokinesia

Knee heel test - normal

CVS EXAMINATION :-

JVP: Normal

INSPECTION:

Chest wall symmetrical

Pulsations not seen

 

PALPATION:

Apical impulse – normal

Pulsations – normal

Thrills absent

 

PERCUSSION:

No abnormal findings

 

AUSCULTATION: 

S1, S2 heard

No murmurs 

No added sounds

3) ABDOMINAL EXAMINATION :- 

INSPECTION:

1. Shape – flat

2. Flanks – free

3. Umbilicus – Position-central, Shape-normal

4. Skin – normal

5. Hernial Orifices - normal 

 

PALPATION:

 

Abdomen is soft and non tender

No hepatomegaly

No splenomegaly 

Kidneys not enlarged, no renal angle tenderness

No other palpable swellings

Hernial orifices normal

 

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent

 

AUSCULTATION:

Bowel sounds – normal 

No bruits, rub or venous hum

4) RESPIRATORY EXAMINATION :- 

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant on percussion

- Bilateral equal air entry, no added sounds heard.

1. Breath sounds -  Normal Vesicular Breath sounds

2. Added sounds - absent

3.  Vocal Resonance - normal

4. Bronchophony, Egophony, Whispering Pectoriloquy absent

PROVISIONAL DIAGNOSIS:

Right hemiparesis due to cerebrovascular accident.

INVESTIGATIONS :

Anti HCV antibodies rapid - non reactive 

HIV 1/2 rapid test - non reactive

Blood sugar random - 109 mg/dl 

FBS - 114 mg/dl

Hemoglobin- 13.4 gm/dl

WBC-7,800 cells/cu mm

Neutrophils- 70%

Lymphocytes- 21%

Eosinophils- 01%

Monocytes- 8%

Basophils- 0

PCV- 40 vol%

MCV- 89.9 fl 

MCH- 30.1 pg

MCHC- 33.5%

RBC count- 4.45 millions/cumm

Platelet counts- 3.01 lakhs/ cu mm

SMEAR:

RBC - normocytic normochromic

WBC - with in normal limits

Platelets - Adequate

Haemoparasites - no 

CUE:

Colour - pale yellow

Appearance- clear 

Reaction - acidic

Sp.gravity - 1.010

Albumin - trace

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells - 3-4 /HPF

Epithelial cells - 2-3/HPF

RBC s - nil 

Crystals - nil

Casts - nil 

Amorphous deposits - absent

LFTs:

Total bilirubin - 1.71 mg/dl

Direct bilirubin- 0.48 mg/dl

AST - 15 IU/L

ALT - 14 IU/L

Alkaline phosphatase - 149 IU/L

Total proteins - 6.3 g/dl

Albumin - 3.6 g/dl

A/G ratio - 1.36

Blood urea - 19 mg/dl

Serum creatinine - 1.1 mg/dl

Electrolytes 

Sodium - 141 mEq/L

Potassium - 3.7 mEq/L

Chloride - 104 mEq/L

Calcium ionised - 1.02 mmol/L

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml

MRI 

Impression:  

Acute infarct in posterior limb of left internal capsule

Old lacunar infarct in left side of pons

Few microhemorrhages in bilateral cerebral hemispheres.

USG: 

No sonological abnormalities detected.

ECG:

               Regular Rhythm,60 bpm

TREATMENT:-

Tab.ECOSPRIN 

Tab.CLOPITAB 75mg PO/OD 

Tab.Stamlo beta

Physiotherapy of right upper limb and lower limb