70 F with fever and pain abdomen since 6 days and left lower limbs cellulitis

 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 70 year old female presented to Casuality with C/o fever since 6 days, abdominal pain since 4 days, pain and swelling of Lt LL since 4 days.

History of presenting illness:

Patient was apparently asymptomatic 6 days ago then she had fever which was continuous associated with chills and rigors , relieved on medication,  no diurnal variation, not associated with cold, cough,  burning micturition. 

H/o pain abdomen which was squeezing type with insidious onset, gradually progressive with no aggravating and relieving factors.

H/o anorexia and nausea present.

No h/o vomitings 

Also Pt C/o pain over Lt LL associated with Itching and swelling which is insidious in onset and gradually progressive.

K/c/o HTN since 10 years( not on regular medication)

K/c/o filariasis to Lt LL since 45 years

N/k/c/o DM2, TB, Epilepsy,CAD,CVA, Hypothyroid.

Personal history:

Diet mixed

Appetite decreased

Sleep Normal

Bowel and bladder movements regular

Addictions none

On General examination:

Pt is oriented to person

Not oriented to time and place, moderately built and nourished.

No Pallor, icterus,clubbing, cyanosis,lymphadenopathy

Left lower limb discoloration and edema

Vitals:

BP: 90/60 mmhg

PR: 96bpm

PR: 20 cpm

CVS: S1 S2 +

RS: NVBS+ BLAE+

P/A: Diffuse Tenderness Present

Investigations:

CBP(3/9/23):

Hb 9.7 gm/dl

TLC 28700

PLC 1.94 L/cumm

LFT:

TB 1.34 mg/dl

DB 0.81 mg /dl

AST 307 IU/L

ALT 89 IU/L

ALP 308 IU/L

TP 4.8 gm/dl

Serum Creatinine: 4.4 mg/ dl

RFT (5/9/23)

Serum Urea 110 mg/dl

Serum Creatinine 3.4 mg/dl

Serum Uric acid  8.4 mg/dl

Sodium 139 mEq/L

Potassium 3.7mEq/L

Chloride 99mEq/L

Ionised calcium 7.9 mg/dl

2d echo:

65%EF

Mild AR +, Moderate TR + with PAH, no MR

No RWMA, No AS / MS,Sclerotic AV

Good LV systolic function

Diastolic dysfunction +, No PE

USG:

Grade II Fatty liver

Right kidney 9.6 x 4.8 cm

Left kidney 11.2 x 5.1 cm

Treatment given:

1. INJ LEVOFLOXACIN 750 mg IV /OD

2. INJ AUGMENTIN 1.2 gm IV BD

3. TAB DEC 100 MG PO BD

4. TAB ECOSPRIN AV 75/10 PO/HS 

5. GRBS monitoring 4th hourly 

6. TAB OROFER XT PO OD

7. TAB LASIX 40 MG PO TID

8. INJ BUSCOPAN IV BD

9. INJ PIPTAZ IV TID for 7 days

Course in the hospital:

Patient was brought to casualty with complaints of fever and pain abdomen since 6 days and swelling of Lt LL since 4 days and was admitted under GS and GM referral was done i/v/o fever, B/l pitting edema of the LL and then case was taken over by GM i/v/o altered sensorium and suspected that altered sensorium is secondary to ? Hypoglycemia (resolved) ?septic Encephalopathy? Uremic Encephalopathy with ulcer over anterior aspect of left LL secondary to filariasis with k/c/o HTN and CAD.

Referred to nephrology i/v/o raised Serum Urea and Serum Creatinine and was  advised to start on dialysis i/v/o uremic Encephalopathy and anuria.

After 2 sessions of haemodialysis, patient recovered from altered sensorium and a total of 5 sessions of haemodialysis were done. 

Meanwhile patient was treated with antibiotics i/v/o sepsis and gradually recovered. 

Serum Urea trend during her stay in the hospital:

152-->154->110-->68-->58-->61-->54-->58-->65-->70.

55 M with Altered sensorium and right pleural effusion

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:

Patient came with complaints of lower back ache since 3 weeks radiating to left lower limbs

History of presenting illness:

Patient was apparently asymptomatic 3 weeks back,then patient complained of lower back ache which is sudden onset, progressive ,aggravates on movement and relieves on rest.

H/o slip and fall from steps 3 weeks back and was taken to an outside hospital and found to have L5 burst fracture on CT pelvis and then he was brought here for further management. 

No h/o lifting heavy weights,fever,burning micturition, Bowel and bladder incontinence. 

Past history of right proximal femur fracture and underwent IMILN 10 years back.

H/o PTCA done one and half year back and is on regular medication 

K/c/o DM II since 20 years and is on T. Metformin 500 mg + T. Voglibose 0.2 mg + T. Glimiperide 2 mg

On General examination :

Patient is conscious and coherent.

No signs of pallor,icterus,cyanosis, clubbing, lymphadenopathy or edema

Vitals at presentation:

Afebrile 

BP: 110/60 mm Hg

PR : 80 bpm

RR : 18cpm 

Systemic examination:

CVS: S1,S2 heard

CNS: NFND

PA : Soft, non tender

RS : BLAE +

B/L of LS spine:

Skin- Normal

Swelling- absent

Tenderness- Present at lumbar region

Tracheostomy was done on 6/9/23

Blood transfusion was done on 12/9/23

Pulmonology referral was done on 30/8/23 and advised for CT Chest and induced sputum for CBNAAT and culture sensitivity.

Nephrology referral was done on 2/9/23 and advised for haemodialysis 

Pulmonology was referral done on 2/9/23 was advised for USG guided tap and ICD placement.

Surgery referral was done on 4/9/23 was advised for aseptic dressings for his bed sore.

Investigations:

29/8/23:

RFT:

Urea 77 mg/dl

Creatinine 1.1 mg/dl

Uric acid  2.9 mg/dl

Na 121 mEq/L

K 4.6 mEq/L

Ca 8.8 mg/dl

Cl 95 mEq/L

LFT:

TB 0.76 mg/dl

DB 0.19 mg/dl

AST 11 IU/L

ALT 13 IU/L

ALP 321 IU/L

ALB 2.59 gm/ dl

Hemogram:

Hb 9 gm /dl

TLC 15300 cells/cumm

PLC 1.8 L/cumm

N/L/E/M/B  87/10/1/2/0

CUE:

Albumin +

Sugar ++++

Pus cells 2-4

Epithelial cells 2-3

ABG:

pH 7.43

pCO2 27.6

pO2 48.1

HCO3 18.1

On 4/9/23:

LFT 

TB 1.63 mg/dl

DB  0.25 mg/dl

AST 27 IU/L

ALT 32 IU/L

ALP 399 IU/L

TP 4.5 gm/dl

ALB 1.86 gm/dl

RFT:

Urea 196 mg/dl

Creatinine 4.5 mg/dl

Uric acid  7.5 mg/dl

Na 133 mEq/L

K 4.4 mEq/L

Ca 8.2 mg/dl

Cl 97 mEq/L

Hemogram(5/9/23)

Hb 7 gm /dl

TLC 23600 cells/cumm

PLC 1.63 L/cumm

On 9/9/23

RFT:

Urea 29 mg/dl

Creatinine 4.5 mg/dl

Uric acid  1.1 mg/dl

Na 132 mEq/L

K 4.9 mEq/L

Cl 99 mEq/L

Hemogram(12/9/23)

Hb 6.5 gm /dl

TLC 20,500 cells/cumm

PLC 2.43 L/cumm

On 15/9/23:

RFT:

Urea 50 mg/dl

Creatinine 0.8 mg/dl

Uric acid 4.2 mg/dl

Na 133 mEq/L

K 3.8 mEq/L

Cl 99 mEq/L

Hemogram(15/9/23)

Hb 6.2 gm /dl

TLC 19,200 cells/cumm

PLC 1.5 L/cumm

2D echo:

Tachycardia,mild LVH

RWMA; Apex,Anterior wall and Lateral wall hypokinesia

Trivial MR/AR , no TR

Sclerotic AV, no AS/MS

EF: 44%, moderate LV dysfunction 

No diastolic dysfunction, no PAH/PE

HRCT CHEST:

Right lower lobe collapse with bronchiectasis

Foci of consolidation in Right middle lobe, lingula and apical segment of left lung lower lobe

Large loculated right pleural effusion extending into the major fissure.

A pocket of loculated mediastinal pleural effusion on Right side

Chronic calcific Pancreatitis 

USG Abdomen- No sonological abnormalities detected

Treatment given:

1. INJ. LEVIPIL 1gm IV/BD given for 16 days

2. INJ NORAD @1.1 ml/hr for 7 days

3. INJ DOBUTAMINE IV for 7 days

4. INJ VASOPRESSIN @5 ml/hr for 6 days

5. INJ FENTANYL + MIDAZOLAM IV for 8 days

6. INJ HEPARIN for 13 days

7. TAB. TOLVAPTAN for 6 days

8. INJ THIAMINE for 7 days

9. INJ HAI for 16 days

10. INJ PIPTAZ 2.25 gm IV TID for 5 days

11. TAB ATORVASTATIN + ASPIRIN 75 mg RT/HS  for 16 days

12. TAB. OROFER XT PO OD for 16 days

13. Nebulisation with IPRAVANT 6th hourly and BUDECORT 4th hourly for 16 days

14. INJ MEROPENEM 500 mg IV BD for 12 days

15. TAB. FLUCONAZOLE 150 mg RT OD for 8 days

16. INJ VANCOMYCIN 500 mg IV BD for 5 days

17. Change of position 2nd hourly and daily dressing of bed sore

COURSE IN THE HOSPITAL:

A 55 year old male with L5(unstable) burst fracture (3 weeks old ) and was transferred from orthopaedics to General medicine i/v/o high GRBS . Patient sugars were controlled with insulin infusion and handed over to orthopaedics. After 1 hr patient developed Altered sensorium and transferred to GM . Altered sensorium was thought to be due to hyponatremia was corrected with 3% NaCl.

Next day i/v/o falling saturation , patient was intubated. He also had bradycardia at that time and CPR was initiated and patient relieved. As breath sounds decreased on Right side of Chest ,HRCT CHEST was done .

Patient developed Heart Failure with 44% Ejection Fraction, D-dimer was found to be elevated initially , pulmonary embolism was suspected and HEPARIN was added to the treatment. Patient had hypotension and was put on inotrope support. As there were raised counts and fever spikes in between, antibiotics were started.

Patient had decreased urine output and increased Serum Urea and Serum Creatinine. Diuretics were added to the treatment and gradually urine output increased. He was maintained on Ventilator and triple inotrope support. His blood pressure improved gradually and gradually inotrope suport was weaned off. Patient had recurrent episodes of seizures in between and was controlled with antiepileptics. 

On 6/9/23, patient was tracheostomised and  maintained on Ventilator. 

Due to low Hb levels 1 PRBC transfusion was done on 12/9/23. 

Sepsis was resolving gradually and antibiotics were de escalated gradually.

Oxygen support was tapered and patient was maintaining on room air on 14/9/23.

On 16/9/23, at around 2 am patient was again connected to Oxygen support i/v/o falling saturation and maintained on it for 2 hours and around 5 am patient had falling saturation even with high flow oxygen support and had bradycardia. 

At around 5 am CPR was started and continued for 30 mins. Inspite of efforts, patient expired .

 

A 60 yr old female with cold and cough since 10 days, fever since 8 days

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 60 yr old female,homemaker who is a resident of Nalgonda came with chief complaints of cold and cough since 10 days, fever since 10 days .

HOPI:

Patient was apparently asymptomatic 10 days ago then she had cough and cold, aggravated with cold climate and relieved with medication. Cough is productive,whitish, non foul smelling and persistent.

H/o watery nasal discharge, on and off, aggravated with cold climate and relieved with medication.

Fever is of low grade, intermittent, not associated with chills and rigors.

Past history:

K/c/o HTN since 20 yrs and is on medication ( Aten 25)

N/k/c/o DM,TB,Asthma,CVA,CAD,Epilepsy 

Daily routine:

She wakes up at 5 am and does her chores like cleaning and mopping the house and by 8 am ,she freshens up and has breakfast and then washes clothes. After that she cooks food have lunch by 12 pm. After that she takes nap and does other activities like gardening, going to market etc and by 7 pm she takes dinner . She then sleeps by 9 pm.

On examination:

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

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

Vitals:

Afebrile

BP: 120/80 mm Hg

PR: 64 bpm

CVS: S1,S2+, no murmurs

RS: BLAE+, No added sounds

CNS: NFND

PA :Soft and non tender

CASE 1:

 [01/09, 10:28] Rakesh Biswas: Corresponding serum protein and LDH? 

Also more importantly what about cell type and cell count?

[01/09, 10:28] Rakesh Biswas: Share the images

[01/09, 10:34] Chetana Keta: Total proteins: 4.5 gm/dl

[01/09, 12:04] Chetana Keta: Pleural fluid cell count -42,000 with predominant neutrophils sir..

[01/09, 21:50] Rakesh Biswas: Ask pulmonologist asap if that would be an indication for ICTD

[02/09, 11:08] Chetana Keta: soap notes 

2/9/23

ICU Bed 3

Dr.Zain(SR)

Dr.Nishita(PGY2)

DR.Govardhini(PGY1)

S: Continuous fever Spikes are present. Stools not passed since 3 days

O: Pt is on Mechanical Ventilator 

GCS- E1V1M1

PR-120bpm

RR-14cpm

BP-110/60 mmhg

@12ml/hr NORAD

@10ml/hr DOBU

@0.2 ml/hr VASOPRESSIN 

ACMV Mode

FiO2 @30

SPO2 94%

RS: BLAE +

Decreased BS in Rt IAA with crepts present in Rt Mammary,IAA

CVS: S1S2 +, No murmurs

CNS: 

Tone :Normal B/L both UL&LL

Power :  Unable to elicit

Reflexes: Absent B/L in both UL & LL

Brain stem reflexes:

Pupillary reflex- absent

Corneal reflex- absent

Conjunctival reflex- absent

Gag reflex- Present

Occulocephalic reflex- Present

P/A- Soft, NT

I/O 2500/200ml

GRBS 174mg/DK

A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago

S/P Post CPR status with chronic calcific Pancreatitis with hyperkalemia with sepsis

P: 

1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr 

2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr 

3. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr

4. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr

5.TAB AZITHROMYCIN 500 mg RT/OD 

6.NEB WITH BUDECORT + IPRAVANT 6 Th hourly 

7.INJ THIAMINE 1 Amp In 100 ml NS IV/BD

8.RT FEEDS 200 ml water 2 nd hourly

200 ml milk 4 Th hourly 

9.MONITOR VITALS TEMP; PR; RR ; spo2

10.POSITION CHANGE EVERY HOURLY

11.INJ HAI ACC to GRBS

12.INJ.MEROPENEM 500mg IV/BD

13.INJ HEPARIN 5000 IU S.c/ QID

14.INJ LEVIPIL 1gm IV/BD

15. T. TOLVAPTAN 15 MG 

RT/BD

16. T. ATORVASTATIN + T. ASPIRIN 10/75 MG PO/HS

17. INJ VANCOMYCIN 500 MG IV BD

T. FLUCONAZOLE 150 MG RT OD

[05/09, 09:23] Chetana Keta: soap notes 

5/9/23

ICU Bed 3

Dr.Zain(SR)

Dr.Nishita(PGY2)

DR.Govardhini(PGY1)

S: No fever spikes

O: Pt is on Mechanical Ventilator 

GCS- E1V1M1

PR-98bpm

RR-14cpm

BP-120/80 mmhg

@0.5ml/hr NORAD

@1.5ml/hr DOBU

ACMV Mode

FiO2 @30

SPO2 96%

RS: BLAE +

Decreased BS in Rt IAA with crepts present in Rt Mammary,IAA

CVS: S1S2 +, No murmurs

CNS: 

Tone :Normal B/L both UL&LL

Power :  Unable to elicit

Reflexes: Absent B/L in both UL & LL

Brain stem reflexes:

Pupillary reflex- absent

Corneal reflex- absent

Conjunctival reflex- absent

Gag reflex- Present

Occulocephalic reflex- Present

P/A- Soft, NT

I/O 1800/1400ml

GRBS 93mg/dl

A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago

S/P Post CPR status with chronic calcific Pancreatitis with hyperkalemia with sepsis

P: 

1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr 

2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr 

3. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr

4.NEB WITH BUDECORT + IPRAVANT 6 Th hourly 

5.INJ THIAMINE 1 Amp In 100 ml NS IV/OD

6.RT FEEDS 80 ml water 2 nd hourly

100 ml milk 4 th hourly 

7. MONITOR VITALS TEMP; PR; RR ; spo2

8.POSITION CHANGE EVERY HOURLY

9.INJ HAI ACC to GRBS

10.INJ.MEROPENEM 500mg IV/BD

11.INJ HEPARIN 5000 IU S.c/ QID

12.INJ LEVIPIL 1gm IV/BD

13. T. ATORVASTATIN + T. ASPIRIN 10/75 MG PO/HS

14. INJ VANCOMYCIN 500 MG IV BD

15. T. FLUCONAZOLE 150 MG RT OD

16. T. OROFER XT PO/OD

17. DAILY DRESSINGS OF BED SORE

CASE II:

Soap notes :

4/9/23

AMC Bed 3

Dr. Zain (SR)

Dr. Nishitha(PGY2)

Dr. Govardhini (PGY1)

S: No fever spikes,Stools not passed.

O:

Pt is oriented to person

Not oriented to time and place

BP: 100/60 mmhg

PR: 96bpm

PR: 20 cpm

GCS: E4V5M6

CVS: S1 S2 +

RS: NVBS+ BLAE+

CNS: NFND

P/A: Diffuse Tenderness Present 

Guarding and rigidity present

A:

Altered sensorium secondary to hypoglycemia with ulcer over anterior aspect of right leg secondary to filariasis with k/c/o HTN and CAD.

P:

1. Iv Fluids NS @ 50 ml/hr

2. INJ LASIX 40 mg IV/BD

3. INJ. PIPTAZ 2.25 gm IV/BD

4. INJ PAN 40 mg IV/BD

5. INJ BUSCOPAN IV/BD

6. TAB. DIETHYL CARBAMAZINE PO/BD

7. TAB MVT PO/OD

8. INJ. ZOFER IV SOS