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

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

1801006074

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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.