1801006074

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.

2nd INTERNAL ASSESSMENT

A 80 yr old M with SOB since 3 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 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

37 year old male, chronic alcoholic with SOB and anasarca

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. 

Case 

A 37 year old male came to the casualty with the chief complaints of shortness of breath since 6 days and generalised swelling of the body.

History of present illness

The patient was apparently asymptomatic 12 years back then he developed generalized swelling all over the body which was insidious in onset and gradually progressed up to 3 months and then he came to our hospital and he was referred to the higher Centre afterwards. When he was in our hospital ,when the BP was checked there was so much variation found between the two arms. In the higher Centre ,he was treated for about a 4 to 5 days and then he became normal and got discharged . For 3 months he didn't take any alcohol or any smoking but after 3 months he again started drinking alcohol and smoking.

Afterwards he had on and off episodes of edema,so he was took a tablet of lasilactone and the edema subsided after taking the tablet. 2 months back he developed  edema which did not subside on medication, so he  came to our hospital and was given  lasix. 5 to 6 days back,he again started developing edema which didn't subside even after taking a higher dose of the tablet and he developed a shortness of breath from the past 4 days. He is not taking enough meals because he is having that SOB and distension of abdomen while sitting and eating. He had  a good appetite but he was not able to eat. On September 14th around morning from 1:00 a.m. he had shortness of breath and around 3:00 a.m. he was not able to take breath and came to our hospital  

H/o dark colored stool since 4 day

H/o decreased urine output since 3 days 

H/o dry cough ( sometimes only ) 

No h/o of fever ,

He is a chronic alcoholic since 2002

He takes alcohol almost daily about a 15 units.

Last consumption of alcohol was 20 days back.

A chronic smoker takes 1 - 2 packs per day 

Past history

Personal history

Diet -mixed

Appetite-normal

Sleep - disturbed(unable to sleep in the night and slept in the mornings)

Bowel- dark coloured stools since 4 days

Bladder- decreased frequency and quantity

Addiction-

Chronic alcoholic since 16 years and nearly for 8 years he consumed daily around 15 units of alcohol

Chronic smoker: 1-2 packs per day.

Family history

General physical examination

Pallor: absent

Icterus: yellowish discoloration of sclera-present

Cyanosis-absent

Clubbing-present

Lymphadenopathy:absent

Edema- generalised edema is present

Systemic examination

Systemic examination:

CVS:

Inspection:

Pericordial pulsations visible (vaguely)

Palpation:

Apex beat felt in 6th intercostal space, 10cm from sternum

Parasternal haeves,thrills are felt.

Percussion: 

Auscultation:

GIT:

?Abdomen distension,soft and non tender

?shifting dullness

?Hepatomegaly

Respiratory:

CNS: No focal neurological deficits present

Investigations

Treatment:

INJ . LASIX 40mg / IV/TID

SALT RESTRICTION<2g/ day

FLUID RESTRICTION <1L/day

TAB MET-XL 2mg/PO/OD

INJ THIAMINE 200 mg in 100 ml NS IV/ TID

BP/PR/RR/ SpO2 charting 2hrly