Sunday 29 January 2023

27year old with b/L pedal edema, facial puffiness and sob

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 

PATIENT CAME TO CASUALITY WITH C/O 

B/L PEDAL DEMA - 20 DAYS

FACIAL PUFFINESS - 20 DAYS

BREATHLESSNESS - 1 DAY 


HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN WAS DIAGNOSED WITH DM-1 AND IS ON INSULIN MITARD (20U-X-16U).SHE HAD 2 EPISODES OF WEAKNESS, UNCONTROLLED SUGARS FOR WHICH SHE WAS ADMITTED FOR A DAY &DISCHARGED ( 1ST EPISODE 5YEARS BACK AND 2ND EPISODE 3 YEARS BACK RESPECTIVELY).ON NOV

2022 PATIENT WAS TAKEN TO GOVT HOSPITAL I/v/O SOB AND WAS DIAGNOSED WITH DENOVO HYPERTENSION, UNCONTROLLED SUGARS ( STARTED ON ? HTN MEDICATION).ON 2ND JAN 2023, SHE HAD EPISODES OF VOMITINGS, LOOSE STOOLS AND WAS ADMITTED IN AIIMS & WAS DIAGNOSED WITH PANCYTOPENIA ,DIABETIC NEPHROPATHY, DILATED CARDIOMYOPATHY,HTN ,VIT D DEFICIENCY RIGHT EYE PSEDUOPHAKIA AND LEFT EYE IMSC WITH HYPERPIGMENTED LESION ON RIGHT FOOT (?

CALLOSITY).6 DAYS BACK SHE DEVELOPED PEDAL EDEMA AND SOB WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE (GRADE 2 TO 4) ASSOCIATED WITH ORTHOPNOEA AND WAS BROUGHT TO OUR HOSPITAL AS HER SYMPTOMS DIDN'T SUBSIDE.


PAST HISTORY:

K/C/O DM TYPE 1 SINCE 10 YEARS AND IS ON INSULIN

K/C/O HTN FROM 2 MONTHS AND ON T TELMA+CLINIDIPINE AND T METXL

H/O OF RIGHT EYE CATARACT SURGERY: 8 YEARS BACK


PERSONAL HISTORY:

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR: PRESENT

PEDAL EDEMA - PRESENT,PITTING TYPE, TILL KNEE NO ICTERUS,CYANOSIS,CLUBBING,

LYMPHADENOPATHY 


VITALS ON ADMISSION:

PR-113 BPM

BP- 220/120MM HG

RR- 26 CPM

SPO2- 72% AT RA

GRBS - HIGH


SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD


2)RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD


3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS


4) CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+


Diagnosis:

TYPE 1 DM WITH UNCONTROLLED SUGARS (RESOLVING)

WITH HYPERTENSIVE EMERGENCY (RESOLVED)

?NEPHROTIC SYNDROME

WITH HFpEF (EF:66%)

BICYTOPENIA SECONDARY TO B12 DEFICIENCY

ANEMIA OF CHRONIC DISEASE

HEPATIC HEMANGIOMA

HTN SINCE 2 MONTHS &DM SINCE 20 YEARS NON PROLIFERATIVE DIABETIC RETINOPATHY]


Treatment:

1.IVF NS @ 30 ML/HR

2.STRICT DIABETIC DIET

3.INJ LASIX 40 MG IV BD

4.T TELMA 40 MG PO BD

5.T CLINIDIPINE 10 MG PO BD

6.T METXL 25 MG PO OD

7.T DYTOR PLUS PO OD

8.T NICARDIA 20 MG PO BD

9.INJ HAI ACCORDING TO GRBS

10.INJ GLARGINE 10 U @ 10 PM

11.T THYRONORM 25 MCG PO OD




BRIEF COURSE IN HOSPITAL: (6/2/23) PATIENT WAS BROUGHT TO THE HOSPITAL WITH ABOVE COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE, HER SUGARS WERE FOUND TO BE HIGH AND BP BEING 220/110MMHG ON PRESENTATION AND WAS TREATED SYMPTOMATICALLY. REFRRALS WERE TAKEN FROM ENDOCRINOLOGIST I//O HIGH SUGARS,NEPHROLOGIST I/V/O HIGH CREATININE AND OPTHALMOLOGIST INIO DIABETIC &HYPERTENSIVE RETINOPATHY CHANGES.INITIALLY FOR HYPERTENSION,SHE WAS TREATED WITH T. TELMA 40MG + CLORTHALIDONE 12.5MG AND T.METXL 25MG AND LATER ON WAS FIXED ON T.NICARDIA 20MG PO/BD(8AM-X-8PM) AND ON ADVISE OF NEPHROLOGIST INJ ERYTHROPOIETIN 2000 UNITS S/C WAS GIVEN. THYRONORM 25MCG WAS STARTED I//O HYPOTHYROIDISM ON 4/2/23 AND PATIENT WAS DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.



Patient has been in constant touch with our doctor’s via PAJR group

Here’s the conversation from today(19/2/23)


Ragi mudda na ??

With jaggery...

That's too much sugar! Please avoid Jaggery 😳



Monday 2 January 2023

24Y/M WITH SOB

 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

A 24 year old male daily wage labourer came to the OPD with a chief complaints of decreased urine output, shortness of breath and vomitings since 4 days. 

HOPI

Patient was apparently asymptomatic 8 days back then he developed severe vomitings due to an excessive binge drinking without any consumption of food. The vomitings were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids. 
Patient developed oral ulcerations later that day. He was taken to a local hospital where medication was provided. 4 days ago he had complaints of shortness of breath (Grade 4)  and decreased urine output with blood in the urine. On taking him to a local hospital, dialysis was advised after which he was admitted to our hospital. 2 days ago the patient was observed to develop a white coating in the mouth and over the tongue( dermatology opinion taken).  



He has no H/o fever, loose stools, pedal oedema, burning micturition, cough 

Past history:
No similar complaints in the past
No H/o HTN, diabetes, asthma, epilepsy and tuberculosis. 

Personal history:
Diet: mixed.             Appetite: decreased 
Bowel and bladder: irregular.      
Sleep: adequate.       Addictions: alcohol and paan. 
Allergies: none.          ( binge drinking episode. Daily      
                                     80ml. )
Family history: not significant 

General examination:
Patient is conscious coherent and cooperative moderately built and nourished

Vitals
Temperature: afebrile.            PR: 83bpm
RR: 22cpm.                            BP: 140/90mmHg

Pallor: absent 
Icterus: present


Cyanosis: absent
Clubbing: absent 
Lymphadenopathy: absent
Oedema : absent

Systemic examination:

Per abdomen: soft on palpation, bowel sounds heard,    no distention present




Respiratory system: no wheeze heard, no crepitus heard, normal vesicular breath sounds heard

CVS: S1 S2 heard, no additional murmurs

CNS: no focal neurological deficits

Investigations:




ECG


USG


Chest Xray


Chest CT



Provisional diagnosis: Alcohol liver disease ,Acute  kidney injury, aspiration pneumonia, oral candidiasis. 

Treatment:
- IV NS
- Inj zofer (SOS)
-Inj Doxycycline 100mg BD
- Inj Thiamine 200mg in 100ml NS TID
- Inj Monolef BD
- Inj Lasix 40mg BD


 

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)         ...