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.
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