55 year old male pyrexia with quadriparesis.

 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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 55 year old male came to opd with chief complaints of  burning sensation of whole body since one week and fever since 1 day.

History of presenting illness:

Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).
He also have complaints of fever since today afternoon associated with chills , relieved on medication.
H/o of  burning micturition since 4-5 days 
No H/o decreased sensations
No h/o bowel and bladder incontinence.
No h/o seizure activity
No H/O cold, cough, sore throat
No H/o nausea , vomiting, pain abdomen.
No H/o loose stools

PAST HISTORY:

Not a k/c/o dmII, htn, thyroid disorders,asthma,epilepsy

GENERAL EXAMINATION:

Patient is conscious, coherent

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema,

Temp: 101.5 degree F

Pr: 98bpm

Rr: 20cpm

Bp:130/70mm Hg

Grbs:151mg/dl

Clinical images of patient

SYSTEMIC EXAMINATION

Cvs:S1 S2 heard , No murmurs 

Rs: BAE +, NVBS

P/A:  NT

CNS:

Tone  UL       LL

R          N         N 

L           N         N

Power : UL        LL

R           2/5       4/5

L           3/5         4/5 

Reflexes -   B    T     S     K      A   P 

RT-             +3   +3   2+   3+     3+   F

LT-              +3   +3   2+  3+     3+   F

INVESTIGATIONS:

4/6/23

5/6/2023

6/6/23

DIAGNOSIS:

  Pyrexia under evaluation with cervical laminectomy 2 months back

TREATMENT:

1. Inj Neomol 1 GM iv/sos ( if temp > 101 F)

2. Inj Monocef 1 GM iv/ bd

3. Inj optineuron  1 amp in 500ml NS /OD

4. Tab dolo 650mg Po/ Sos

5.tab pregabalin 75mg po/Hs

50 yr female with diabetic ketoacidosis.

 5th june 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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 50year old female patient who resident of nalgonda presented to casualty with chief complaints of pain abdomen 7 days back and regurgitation of food .

History of presenting illness 

Patient was apparently asymptomatic 15 years back then she had a episode of giddiness,was taken to hospital and diagnosed with Hypertension and on regular medication MET-XL25 mg.

Till 6 years back she is doing well developed Bilateral knee joint pain for which she was advised to take analgesics .

She started to take antacid medication since 4 years 

1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .

Patient complaining of loss of appetite, regurgitation of food, difficulty in swallowing

5 days back 

1 episode of vomiting bilious ,non projectile ,food as content  

3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood  

Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors 

Pt presented to casualty on 3/6/23 evening 

On checking her GRBS it was found to be HIGH.

URINE for ketone bodies found to be positive.

Past History:

Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.

Family History 

Not significant

Personal History:

Pt is having loss of appetite, vowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No addictions.

Daily routine:

Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and used to stay at home

Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.

General Examination:

Pt is conscious, coherent,cooperative 

Pallor present

no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.

Clinical images:

VITALS:

Bp-130/80 mm Hg

Pr- 97 bpm

Rr-25 cpm

Temperature:Afebrile

Spo2: 98%@RA

GRBS- HIGH

SYSTEMIC EXAMINATION:

P/A:

Inspection:

Abdomen is distended

Infra umbilical vertical scar present

No sinuses, pulsations,  peristalsis.

Umbilicus is central and inverted

All quadrants of Abdomen move equally  with respiration.

Palpation:

No local rise of temperature

Tenderness present in the Right ,Left Hypochondrium and Epigastrium.

No fluid thrill 

Liver is palpable

Spleen not palpable

Percussion:

Resonant note is heard on percussion

 shifting dullness negative

Auscultation:

Bowel sounds are heard.

Cvs:

S1,S2 heard No murmurs

CNS:

No focal neurological deficit 

Rs:

Bae+

Normal vesicular breath sounds heard.

Investigations:

URINE for Ketone bodies: Positive 

Serum osmolality:

Glycated Hemoglobin 

Abg and serum electrolyte values

Hemogram 

Liver function test:

Usg Abdomen:

No sonological abnormalities detected

Chest X ray:

Ecg: 

Provisional Diagnosis:

?Diabetic ketoacidosis ?Starvation ketoacidosis with Acute Gastroenteritis with Denovo DM2.

Treatment:

1.IVFluids NS @100ml/hr

2.Inj.HAI  infusion 1ml(40U)in 39 ml NS@4ml/hr increase or decrease according to GRBS

3.IV 5Dextrose@50ml/hr increase or decrease according to GRBS

4.Strict I/O CHARTING

5.monitor Vitals Hourly

45 year old male with abdominal distension.

 June 1st 2023

 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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.

Date of admission - 29 May 2023

45 year old male ,lorry driver by occupation,resident of Nalgonda came to the opd with chief complaints of  

Abdominal distension since 4-5 days

Abdominal bloating since 4-5 days

B/L lower limb swelling since 4 days

Shortness of breath since 3 days

History of present illness :

He was apparently asymptomatic 12 days back then he developed fever which subsided after 3 days. 

Then there was yellowish discoloration of eyes and history of passing dark coloured urine since 9 days.

Bilateral swelling of lower limbs (extending upto knee, pitting type) insidious in onset ,gradually progressive, no aggravating and relieving factors.

Abdominal distension since 5 days ,insidious in onset ,gradually progressive,no aggravating and relieving factors associated with bloating and SOB.

Slurred speech since 2 days.

No h/o chest pain ,palpitations 

No h/o deceased urine output,burning micturition.

Past history :

K/c/o DM since 4-5 years on medication Tab Metformin 500mg po BD 

N/k/c/o HTN CVA CAD TB EPILEPSY.

Personal history:

Diet :mixed 

Appetite: decreased 

Bowel habits - reduced

Micturition - normal

Sleep: adequate

Addictions: chronic alcoholic since 20 years, 3-6 units per  day, last date of alcohol consumption - 28/5/23, 2 units of beer.

Smoking - regular since 25 years, daily one pack (beedi or cigarette)

Family history: not significant

General examination:

Patient is conscious, coherent and cooperative.

Well oriented to time and place.

Pallor- present

Icterus - present

Edema - present 

No clubbing, cyanosis and lymphadenopathy 

Pallor-present 

Icterus present 

Edema present 

Vitals:

Temp:101.5F

Bp:90/60mm hg

PR:96bpm

RR:20cpm

Systemic examination:

CVS:s1s2+,no murmur

RS:BAE+,no added sounds 

P/A: 

Inspection; Shape of abdomen; distended 

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:

No tenderness 

No organomegaly

Auscultation:

Bowel sounds heard 

CNS: NFD

Investigations :

Treatment:

Inj.pan 40mg IV/OD 

Inj.thiamine 200mg in 100ml Ns /IV /TID

Inj.zofer 4mg/IV/TID

Inj.lasix 20mg IV/OD 

A 34 year old male with seizures.

1st September 2022

This is online E log book to discuss our patient’s de-identified health data. 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 patients’ clinical problems with collective current best evidence-based inputs. 

This e-log book also reflects my patient centred online learning and your valuable inputs 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 diagnosis and treatment plan.

A 35 year old male came with chief complaints of seizures which lasted for 30 minutes.

History of present illness:

Since childhood - patient had developmental delay and delayed milestones.

5 years ago - similar complaint of seizure which lasted for 5 minutes and subsided after consulting a local doctor. And not on any medication since then.

Patient was apparently normal 3 days back and developed involuntary, generalized, to and fro movements of upper  limbs and lower limbs which lasted for half an hour.

The episode is associated with upward rolling of eyeballs and frothing.

Patient has not regained consciousness for half an hour during the episode of seizure.

No history of tongue bites during the episode of seizure.

No history of fever, headache, vomiting and giddiness.

Past history:

No history of DM and hypertension

Patient is a known case of cerebral palsy.

Personal history:

Not married due to developmental delay.

Appetite - normal

Mixed diet

Bowel habits - regular

Micturition - normal

No allergies and addictions

Family history:

Not significant.

General Examination:

The patient was conscious, coherent but not co-operative and not well oriented to time, place and person.

Normally built and nourished.

Pallor absent 

Icterus absent 

Cyanosis absent 

Clubbing absent 

Edema absent 

Lymphadenopathy absent 

Vitals:

Temperature - afebrile

Pulse rate- 86/min

Respiratory rate- 14/min

Bp- 100/70 mm hg

SpO2- 98%

Systemic examination:

Cardiovascular system- no thrills and murmurs, S1 and S2 heard.

Respiratory system - normal vesicular breath sounds heard. 

No dyspnea and wheezing.

Abdomen - shape- scaphoid, no tenderness. 

Central nervous system- 

Tone is increased in both upper and lower limbs.

Power is 3/5 in all four limbs.

Provisional diagnosis:

Generalized tonic seizures

Status epilepticus?

Known case of cerebral palsy.

Investigations :

Treatment:

IV fluids - 100ml/ hr 

Inj levipil- bd (500 mg - x - 250 mg).

Inj monocef - 1gm / iv / bd 

Inj pan - 40 mg / iv / od

Inj zofer- 4 mg iv 

Inj loraz- 2 cc/ iv 

Inj optineuron - 1 amp in 100 ml ns /iv 

Tab dolo - 650 mg