Sunday 18 December 2022

13 YEAR OLD WITH GROSS HAEMATURIA AND ANASARCA

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 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 inputs on the 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.

13Y/F presented to the opd with chief complaints of 

1) fever since 36 days

2) red coloured urine since 33 days 

3) pedal edema since 30 days


HOPI:

Patient was apparently asymptomatic 36 days ago , then developed fever which was low grade, intermittent type, relieved with medication not associated with chills & rigors . Vomitings 4 episodes /day for 3 days , content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery , not associated with abdominal pain, blood in stools .

Patient presented to the opd with complaints of hematuria since 33 days whole stream of urine red in colour. No burning micturition and frothiness of urine 

Then patient developed generalised swelling of body ,initially both lower limbs pedal edema then abdominal distension and facial puffiness.No h/o sore throat , decreased urinary output.

PAST HISTORY:

No history of similar complaints in the past

Not a k/c/o of DM, HTN, epilepsy, TB, CAD,CVD


PERSONAL HISTORY :

Appetite: Normal
Diet: Mixed
Sleep: adequate
Bowel and bladder: regular
Occupation: Student

MENSTRUAL HISTORY :
Attained menarche at 11 years
Regular cycles, flow is for 4 days , not associated with any pain and clots
LMP:27/11/22

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

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


Pallor- present



Icterus- absent
Clubbing-absent
Lymphadenopathy- absent
Cyanosis- absent
Pedal edema - present (B/L)





VITALS: 

B.P:110/80 mmhg
P.R:86bpm
R.R: 16cpm
Temp:98.5F
SPO2: 99%@ RA


PER ABDOMEN:

Inspection- umbilicus inverted, all quadrants moving equally with respiration , no scars sinuses and engorged veins with visible pulsations

Palpation: soft , non tender
Auscultation: BS heard


CARDIOVASCULAR SYSTEM:

 on inspection : chest is elliptical bilaterally symmetrical 

Palpation: apex beat felt 

All inspectory findings confirmed



RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 


Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal


Percussion: resonant bilaterally 


Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.


CENTRAL NERVOUS SYSTEM:


Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes - 

Triceps  +2  +2

Biceps.  + 2  +2

Supinator +2  +2

Knee +2  +2

Ankle +2  +2


PROVISIONAL DIAGNOSIS:

POST INFECTIOUS GLOMERULONEPHRITIS ?SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI


INVESTIGATIONS :




Fever chart :




URINE SAMPLE 


ANA PROFILE 

TREATMENT:


17/12/22

SALT AND FLUID RESTRICTION 

Vitals monitoring 4th Hrly


18/12/22


13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o generalised swelling of body



O


Pt is C/C/C


BP:120/90mmHg


PR:74bpm


RR:18cpm


SpO2:98% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


POST INFECTIOUS GLOMERULONEPHRITIS SECONDARY TO ECOLI/SALMONELLA/STREPTOCOCCI


P


SALT AND FLUID RESTRICTION 


Vitals monitoring 4th Hrly


19/12/22

13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o generalised swelling of body



O


Pt is C/C/C


BP:110/70mmHg


PR:80bpm


SpO2:98% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


POST INFECTIOUS GLOMERULONEPHRITIS ? SECONDARY TO SALMONELLA/STREPTOCOCCI/ECOLI


P


SALT AND FLUID RESTRICTION 


TAB LASIX 40mg PO/BD


Plan for renal biopsy


20/12/22


13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o b/l lower limbs

No shortness of breath



O


Pt is C/C/C


BP:100/80mmHg


PR:72bpm


SpO2:98% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


POST INFECTIOUS GLOMERULONEPHRITIS ? SECONDARY TO SALMONELLA/STREPTOCOCCI/ECOLI


ANEMIA OF CHRONIC INFLAMMATION 


P


SALT AND FLUID RESTRICTION 


TAB LASIX 40mg PO/BD


Vitals monitoring 4th Hrly


Plan for renal biopsy today



21/12/22


13 year old girl, high school student came to the OPD with history  of fever 36 days ago high grade, continuous type relieved with medication. Vomitings 4 episodes /day, content food particles, non bilious, non projectile. Loose stools 3-4 episodes/day, watery .

No presented with the complains of hematuria since 33 days,  gross hematuria whole stream of urine.Both lower limb  pedal edema since 30 days, pitting type.

No history of sore throat, decreased urine output .




C/o b/l lower limbs

No shortness of breath



O


Pt is C/C/C


BP:110/80mmHg


PR:72bpm


SpO2:98% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


POST INFECTIOUS GLOMERULONEPHRITIS


ANEMIA OF CHRONIC INFLAMMATION 


P


SALT AND FLUID RESTRICTION 


TAB LASIX 40mg PO/BD


Vitals monitoring 4th Hrly


Plan for renal biopsy today




Tuesday 13 December 2022

80year old with fever ,burning micturition and dysphagia

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 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 inputs on the 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


80 year old female presented with the complains of fever since 3 months,

burning micturition since 3 months,

difficulty in swallowing since 1 month 


HISTORY OF PRESENT ILLNESS

Patient was apparently assymptomatic 3 months back then developed fever associated with burning micturition & abdominal pain for which she was brought to the hospital and was admitted (pyrexia of unknown origin) and was discharged on 25/10/22 post which she had no complaints till  19/11/22 , when patient had similar complaints and was treated at local hospital 

Previous record of hospital administration of patient 


https://nehareddygaddam.blogspot.com/2022/10/72-female-with-fever-burning.html?m=1


On 10/12/22 patient presented to our hospital with complaints of fever since 20 days associated with burning micturition 

Fever is low grade and continuous associated with chills & rigors , relieved partially with medication

K/c/o DM :20years on TAB.cinod T 

HTN :on Inj.HAI 8u-x-6u

Surgery: Right PFN 11yrs ago


PERSONAL HISTORY:

Decreased appetite takes mixed diet, irregular bowels( Type 1 Bristol stool) ,normal micturition , no allergies 


MENSTRUAL HISTORY:

Age of menarche - 15yrs

Menopause attained 30 years back


OBSTETRIC HISTORY:

Age at marriage-12yrs

Gravida 3 (all 3 are Full term NVD)

1st male , 2nd female - died

3rd - female alive 


GENERAL PHYSICAL EXAMINATION 

Patient conscious coherent cooperative 

Moderately built and nourished

Pallor present



No, icterus, cyanosis, clubbing, lymphadenopathy 




 Vitals

Bp:150/90mmhg

RR-20cpm

PR-98bpm

SPO2-94%

GRBS-343mg/dl (inj. HAI 14 units given)

TEMP-98.3F


SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM EXAMINATION-


Inspection

Drooping of right shoulder 

No engorged veins , discharging sinuses , scars

Apex beat cannot be seen

Trachea appears to be central  


Palpation

Inspectory findings are confirmed 

Trachea central

Decreased movements on right side 

Vocal fremitus more on right side 

Tactile fremitus more on right side 


Percussion

Dull note on right side


Auscultation

Inspiratory crepts in the right inframammary area 

Rest of the lung fields normal vesicular breath sounds 


CVS: S1 , S2 present

Pansystolic murmur present


CNS: NAD 


P/A: SOFT, TENDER


PROVISIONAL DIAGNOSIS:  

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS


INVESTIGATIONS:

REPORTS-



Fever chart-





2D ECHO -



ECG-



BACTERIAL CULTURE AND SENSITIVITY:


USG ABDOMEN :



USG NECK



X-RAY OF NECK:



CHEST X-RAY PA VIEW



HRCT CHEST:(done on 21/10/22)



HRCT CHEST DONE ON 19/12/22






REFERRALS: 

                  CARDIOLOGY REFERRAL



SURGERY REFERRAL



ENT REFERRAL




PULMONOLOGY REFERRAL 





DVL REFERRAL



TREATMENT: 

10/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

Fever 


O

Pt is C/C/C

BP:110/70mmHg

PR:82bpm

RR:24cpm

SpO2:95% on RA

Temp :101 F

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly


A

PYREXIA UNDER EVALUATION 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. DOLO 650 MG PO/TID

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


11/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

2 fever spikes @ 2:00 pm- 101f 

@10pm - 102f



O

Pt is C/C/C

BP:150/90mmHg

PR:88bpm

RR:24cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly


A

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ?  WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. DOLO 650 MG PI/TID

TAB. ATT  3 TABLETS /DAY

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


12/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

2 fever spikes @ 2:00 pm- 101f 

@10pm - 102f

C/o neck pain on left side



O

Pt is C/C/C

BP:150/90mmHg

PR:88bpm

RR:24cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

Crepts - INFRA AXILLARY

PA-soft no organomegaly


A

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. ATT  3 TABLETS /DAY

TAB. CINOD T PO/OD 

INJ. HAI ACCORDING TO GRBS- S/C

TAB. BENADON 40 MG PO/OD

INJ.FALCIGO 120mg IV/0th hr-12th hr-24th hr-48th hr

Tab NICARDIA 10mg PO/OD 

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


13/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

1fever spike at 8:00 am- 101f  and difficulty in swallowing 



O

Pt is C/C/C

BP:160/90mmHg

PR:76bpm

RR:26cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly


A

PYREXIA OF UNKNOWN ORIGIN WITH ? PUL TB (ON ATT) WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD D 4

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. ATT  3 TABLETS /DAY

TAB. CINOD T PO/OD 

TAB DOLO 650 MG PO/TID

INJ. HAI ACCORDING TO GRBS- S/C

TAB. BENADON 40 MG PO/OD

TAB ULTRACET 1/2 TAB PO/QID

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly



14/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

1fever spike at 2:00 am- 101f  and difficulty in swallowing 



O

Pt is C/C/C

BP:160/90mmHg

PR:76bpm

RR:26cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly


A

PYREXIA OF UNKNOWN ORIGIN WITH ? PUL TB (ON ATT) WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD D 4

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. ATT  3 TABLETS /DAY

TAB. CINOD T PO/OD 

INJ. HAI ACCORDING TO GRBS- S/C

TAB. BENADON 40 MG PO/OD

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly

Plan for ENT refferal and flexible laryngoscopy

Plan for BAL after CBNAAT report tomorrow


15/12/22


Patient presented with complaint of fever since 3 months on and off,burning micturition since 3 months, difficulty in swallowing since 1 month


S

2 fever spikes @ 2:00 pm- 101f 

@10pm - 102f

C/o neck pain on left side



O

Pt is C/C/C

BP:150/90mmHg

PR:88bpm

RR:24cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

Crepts - INFRA AXILLARY

PA-soft no organomegaly


A

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 


INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. ATT  3 TABLETS /DAY

TAB. CINOD T PO/OD 

INJ. HAI ACCORDING TO GRBS- S/C

TAB. BENADON 40 MG PO/OD

INJ.FALCIGO 120mg IV/0th hr-12th hr-24th hr-48th hr

Tab NICARDIA 10mg PO/OD 

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


16/12/22



Patient presented with complaint of fever since 3 months ,burning micturition since 3 months intermittent difficulty in swallowing since 1 month 

Constipation since 3-4 years



No Fever spikes 

C/o neck pain


O


Pt is C/C/C


BP:170/90mmHg


PR:92bpm


RR:18cpm


SpO2:95% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


Crepts - INFRA AXILLARY


PA-soft no organomegaly


A


PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA UNDER EVALUATION (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 




 TAB CINOD T @ 8AM PO/OD

TAB CINOD @ 8PM PO/OD


INJ.FALCIGO 120mg IV/48th hr


Tab NICARDIA 10mg PO/SOS


Vitals monitoring 4th hrly 


GRBS monitoring 6th hrly

 

Plan for BAL today,CBNAAT negative


17/12/22


Patient presented with complaint of fever since 3 months ,burning micturition since 3 months intermittent difficulty in swallowing since 1 month 

Constipation since 3-4 years



Fever spikes at 10:00 am - 101 F

After 5 episodes of loose stools yesterday no further complaints of loose stools since night

C/o neck pain



O


Pt is C/C/C


BP:180/90mmHg


PR:98bpm


RR:18cpm


SpO2:96% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA SECONDARY TO BLOOD LOSS OR NUTRITIONAL WITH CHRONIC CONSTIPATION(NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 




TAB CINOD PO/BD


TAB MET- XL 25 MG PO/OD


TAB NICARDIA 10mg PO/SOS


TAB ULTRACET 1/2  tab PO/QID


Vitals monitoring 4th hrly 


GRBS monitoring 6th hrly


Plan for HRCT  and to withhold ATT today


18/12/22

Patient presented with complaint of fever since 3 months ,burning micturition since 3 months intermittent difficulty in swallowing since 1 month 

Constipation since 3-4 years



1 Fever spike @ 2PM

C/o neck pain



O


Pt is C/C/C


BP:160/50mmHg


PR:90bpm


RR:20cpm


SpO2:97% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA SECONDARY TO BLOOD LOSS OR NUTRITIONAL WITH CHRONIC CONSTIPATION(NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 




TAB CINOD PO/OD


TAB TELMA 40mg PO/OD 


TAB NICARDIA 10mg PO/SOS


TAB ULTRACET 1/2  tab PO/QID


Vitals monitoring 4th hrly 


GRBS monitoring 6th hrly


19/12/22


Patient presented with complaint of fever since 3 months ,burning micturition since 3 months intermittent difficulty in swallowing since 1 month 

Constipation since 3-4 years



1 Fever spike @ 2PM

C/o neck pain



O


Pt is C/C/C


BP:150/70mmHg


PR:76bpm


RR:20cpm


SpO2:97% on RA


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


PYREXIA OF UNKNOWN ORIGIN WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA SECONDARY TO BLOOD LOSS OR NUTRITIONAL WITH CHRONIC CONSTIPATION(NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 





TAB TELMA 40mg PO/OD 


TAB METXL 25mg PO/OD


TAB NICARDIA 10mg PO/SOS


TAB ULTRACET 1/2  tab PO/QID


Vitals monitoring 4th hrly 


GRBS monitoring 6th hrly 


Plan for HRCT TODAY


20/12/22


Patient presented with complaint of fever since 3 months ,burning micturition since 3 months intermittent difficulty in swallowing since 1 month 

Constipation since 3-4 years



1 Fever spike @ 1AM 

neck pain subsided



O


Pt is C/C/C


BP:150/70mmHg


PR:80bpm


RR:20cpm


SpO2:97% on RA


Grbs:102mg/dl


Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


80F WITH PYREXIA OF UNKNOWN ORIGIN ASSOCIATED WITH SCM TENDINITIS AND CHOLELITHIASIS , ANEMIA OF CHRONIC INFLAMMATION WITH HYPERTENSION & DIABETES.





TAB TELMA 40mg PO/OD 


TAB METXL 25mg PO/OD


TAB AMLONG 5mg PO/OD 


TAB NICARDIA 10mg PO/SOS


INJ HAI 4-4-4


INJ NPH 4-x-4


Vitals monitoring 4th hrly 


GRBS monitoring 7th hrly 


HRCT was done yesterday 

Inference - 

1) non resolving consolidation

2) Bronchoalveolar carcinoma


Planning for Usg guided biopsy & aspiration today


Patient was referred to higher center on 20/12/22


Follow up-

Upon referral patient was taken to another esteemed hospital where the necessary investigations were done and these are the reports:

















Internship assessment

 This blog is made based on my experience that showcases my competency and pitfalls UNIT duties —-First 15 days (12/12/22-26/12/22)         ...