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.
CASE:
A 54year old man who was a toddy collector now being a panchayat member he is solving the conflicts of the villagers resident of Yadagirigutta came with chief complaints of absence of urine output since 2days (01/08/2022) night 10pm and sob since 2 days
History of presenting illness:
Patient was apparently asymptomatic 20days back then had fever with chills and rigors, evening rise of temperature and vomitings at night then went to a hospital 2 days later and was given medication but fever did not subside and went for a checkup 5days later and was found to have low WBC count and was given medication and went for a checkup 1week later was found to have incresed bilirubin level and used herbal medication.
5days ago, he had fever, yellowish discolouration of eyes(Serum bilirubin was 2.4mg/dl) and also has pedal edema(upto ankle).
Since 2 days(01/08/2022) night 10pm he has no urine output(anuria), abdominal distension, shortness of breath(breathing with mouth).
From yesterday(on 3-8-2022)night he is drowsy.
He underwent dialysis for uremia on 4-8-2022.
He died on 5-8-2022.
Daily routine:
He wakes up at 6am in the morning goes to a walk and returns home and have tea at 7:30am. He takes bath and eats his first meal at 9:30am and goes to out to take part in resolving villagers conflicts and comes home after alcohol in the evening at 8:00pm and have his dinner at 8:30pm and sleeps
Past history:
History of fracture of head of femur in Jan,2022 and underwent reconstructive surgery with prosthesis and was on bed rest for 2 months and he has pain after walking for long distances.
Not a known case of Diabetes, hypertension, epilepsy, asthma, CAD, Thyroid disorders,Tuberculosis.
Personal history:
Diet-mixed
Appetite: normal
Bowel movements: no stools passed since 2 days(02/08/2022)
Bladder movements: absence of urine output
Addictions: He used to take around 180ml of alcohol daily for past 20years and he has been taking it occasionally for the past 7months and did not take for the past 20days
He smokes a cigarette per day for past 1year and did not smoke any for past 20days
Family history:not significant
General examination:
Patient is conscious, coherent and cooperative
He is moderately built and moderately nourished
Pallor-absent
Icterus-present
Clubbing-absent
Cyanosis-absent
Generalised lymphadenopathy-absent
B/l pedal edema- upto the ankle pitting type
Vitals:
Temperature:
Pulse rate:92bpm
Blood pressure:110/70mm of hg
Respiratory rate:29cpm
SpO2: 98%
Grbs:86gm/dl
Systemic examination
Per abdomen:
Inspection:
Abdominal distensted
Scars of burns occurred in childhood
No sinuses, dilated veins
Umbilicus is inverted
Palpation:firm, tender(over right hypochondrium)
Percussion:-
Auscultation:Bowel sounds heard
Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
Higher motor functions:
MMSE: couldn't be assessed
Speech:
Signs of meningeal irritation-present
Neck stiffness-present
Brudzinski sign-
Kerning sign-
Motor:
Right left
Tone: UL normal normal
LL normal normal
Power:UL couldn't assess
LL couldn't assess
Reflex:
Superficial reflexes: Right left
Corneal
Conjunctival
Deep tendon reflexes:
Biceps
Triceps
Supinator
Knee ++ ++
Ankle + +
Plantar extensor extensor
Sensory: Right left
Touch
Pain
Vibration
Cerebellar functions:couldn't be assessed
Gait: couldn't be assessed
Provisional diagnosis:
Acute kidney injury and acute liver injury
Uremic encephalopathy.
Investigations :
Treatment:
On 3-8-2022:
Inj.PAN 40 g I.v OD
Inj. CEFTRAONN 1gm I.v BD
Inj. LASIX 20mg I.v BD
Inj. DOXY 100mg I.v BD
Tab. ADICTONE 25mg p.o BD
Tab. UDILI 300mg p.o BD
Tab. UITRACET 1/2 P.o BD
SYR. LACTULOSE 10ml p.o BD
Neb. ASTHALINE p.n BD
I.v NS RL @30ml/hr
Inj.TRAMADOL plus NS 300ml.
On 4-8-2022:
Inj.PAN 40 g I.v OD
Inj. CEFTRAONN 1gm I.v BD
Inj. LASIX 20mg I.v BD
Inj. DOXY 100mg I.v BD
Tab. UDILI 300mg p.o BD
Tab. UITRACET 1/2 P.o BD
SYR. LACTULOSE 10ml p.o BD
Neb. ASTHALINE p.n BD
Inj.TRAMADOL 1ampi.v
Tab.DOLO 650mg p.o sos
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