Final medical practical- long case

  General medicine final practical: Long case 

This is an online E log book to discuss our patient's   

de-identified health data shared after taking her guardian's signed informed consent. 

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 patient's clinical problems with collective current best evidence based inputs.

MUSKAAN GOYAL 

Hall ticket no. 1701006120

DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

DOA: 19/05/2022 

A 46yr old male was resident of nalgonda  , farmer by occupation was brought to medicine OPD with complaints of :

Chief compliants:

Burning micturition present since 10 days 

Hiccups since 3 days 

Vomiting since 2 days

Giddiness, drowsiness and deviation of mouth to right since yesterday night

HOPI: 

Pt was apparently asymptomatic 

10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on Oral hypoglycemic agents 10 yr back, which pateint has been taking on and off due to financial crises.

Oral hypoglycemic agents were converted to insuline and pt underwent cataract surgery 3 yrs ago . Pt has been taking insulin three times a day befor food regularly.

h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee which turned into wet gangrene , eventually  ended with below knee amputation 1yr back.

Delayed Wound healing present- wound healing took 2 months time to heal.

10 days back ,then he developed burning micturation , not associated with fever and decreased urine output. 

3 days back then pateint complaints of hiccups

2 days back, then pt developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.

Pt c/o deviation of mouth and giddiness since yesterday night(18/05/2022) and was brought to the hospital and GRBS was checked which was high, for which he was given NPH 10 IU and HAI 10 IU

No c/o fever/cough/cold/ abdominal pain

No c/o chest pains/palpitations/syncopal attacks

Past history:

Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD

Not on any other medication

No h/o blood transfusion

Personal History:

Married

Appetite-Normal

Diet-Vegetarian

Sleep - adequate

Micturition- burning micturition present.

Bowel- regular. 

DIET OF THE PATIENT:

Patient take three meals.

Morning has idly , dosa , vada any sort of tiffin.

Afternoon has rice curd vegetable dal. 

Night has jawal.

No smalls meals...patient takes biscuits whenever he experiences an hypoglycemic attack ( feeling of giddiness , sweating )

Habits/Addiction:

Alcohol- 

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.

Family history:

Not significant

General Examination: 

 Pt examined in well lit room and with informed consent

Pt is conscious, cooperative and coherent and we'll Oriented to time place person.

Well built and moderately nourished

Pallor present

No icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema

No  signs of dehydration

 

Vitals at the time of Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 101F

SpO2: 98% on RA

GRBS: 124 mg/dL

Systemic Examination:

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – full

Umbilicus –central ,  inverted.

All quadrants of abdomen are moving with respiration.

No dilated engorged veins

No visible pulsations, visible peristalsis and scars.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- 

Liver : palpable just below costal margin ( right)

Sleep : not palpable 

Kidney : not palpable

PERCUSSION:

There is no free fluid

Percussion of liver for liver span : 12cm

Percussion of spleen- dull  note

AUSCULTATION:

Bowel sounds heard.

Other systems:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

CNS: 

Higher function test: 

Slurred speech

Cranial nerves : intact 

Motor system :   

1, Bulk :                    right.                    Left 

Upperlimb          normal.                Normal

Lowerlimb.        thigh -N.                Normal 

                          Below knee amputated on R side

2,  Tone : 

Upperlimb.          Normal.             Normal 

Lowerlimb.         Normal.             Normal 

 3, Power :

Neck:. Normal 

Trunk:. Normal

         Upper limb       5                        5

         Lower limb       5                        5 

 4, Reflexes 

                                     Right           Left 

                      Biceps    2+.                  2+

                     Triceps    2+                    2+

                  Supinator.   2+                   2+

                Knee               2+.                 2+

               Ankle               2+.                2+

         Planter reflex    Amputated   flexion

Sensory system : normal

Meaningal signs  : negative

 Investigations:

19/05/2022: ( on admission)

X ray KUB:

CT scan 

USG abdomen pelvis

Urine examination:

Complete blood picture:

Liver function test:

20/5/2021

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

Culture report: Klebsiella Pneumonia positive

2D Echo:

21/5/2021:

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22/5/2021:

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23/5/2021:

Hb: 6.7

TLC : 21000

Platelets: 1.52 lakh

Urea: 160

Creatinine : 5 

Uric acid : 7.4

Na+ : 150

K+ : 5.4

Cl- : 97 

24-5-2021 to 30-5-2021 : 

 Complete blood picture and serum electrolyte

      

On 7/6/2021:

Temperature charting:

 

Interpretation: 

after one week of use of meropenam the fever spikes have shown a fall and there is no new complaint by patient. The WBC counts have also reduced and patient's condition have been improving

Apraxia test:

Constructional apraxia :

Provisional diagnosis:

Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis

H/o Type 2 DM since 10 yrs

Treatment:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

INJ. COLISTIN 2.25 MU IV OD

SOAP NOTES:

DAY1

DOA: 19/05/2022

S:

C/o vomitting present

Pt is c/c/c

Pt is not drowsy

Pt c/o mild abdominal pain- diffuse

O:

BP: 120/70 mmHg

HR:96 bpm

RR: 20 cpm

TEMP: 98.7 F

SPO2:98% on RA

GRBS: 256 mg/dl

P:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

DAY2 (20/5/2021)

DOA: 19/05/2022

S:

C/o vomitting present

Pt is c/c/c

Pt is not drowsy

Pt c/o mild abdominal pain- diffuse

O:

BP: 120/70 mmHg

HR:96 bpm

RR: 20 cpm

TEMP: 98.7 F

SPO2:98% on RA

GRBS: 256 mg/dL

P:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

DAY4( 22/5/2021)

DOA: 19/05/2022

S:

No new complaints 

O:

BP: 100/60 mmHg

HR:76 bpm

RR: 20 cpm

TEMP: 98.7 F

SPO2:98% on RA

GRBS: 148 mg/dL

Tx:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

DAY5 ( 23/5/2021)

DOA: 19/05/2022

S:

No new complaints 

O:

BP: 100/60 mmHg

HR:78 bpm

RR: 20 cpm

TEMP: 98.7 F

SPO2:98% on RA

GRBS: 148 mg/dL

I/O:2950mL/1700mL

Tx:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

DAY7

SOAP NOTES ICU BED-6, DAY -7

DOA: 19/05/2022

S:

No complaints

O:

BP: 110/70 mmHg

HR:72 bpm

RR: 20 cpm

TEMP: 98.3 F

SPO2:98% on RA

GRBS: 215 mg/dL

Tx:

INJ. MEROPENEM 500mg IV BD (Day 7)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

DAY8

SOAP NOTES ICU BED-6, DAY -8

DOA: 19/05/2022

S:

1 fever spike since yesterday 

Sensorium improving

Abdominal pain subsided

O:

BP: 110/70 mmHg

HR:74 bpm

RR: 20 cpm

TEMP: 98.3 F

SPO2:98% on RA

GRBS: 215 mg/dL

Tx:

NBM till further orders

INJ. MEROPENEM 500mg IV BD (Day 9)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

SDP Transfusion done I/v/o low platelet count

Pre transfusion counts

Hb: 7.0 g/dL

TLC:22000

PLt:26000

Post transfusion counts

Hb:6.5 g/dL

TLC: 17700

PLt:7000

DAY 9

DOA: 19/05/2022

S:

Sensorium improving

Abdominal pain subsided

O:

BP: 120/70 mmHg

HR:72 bpm

RR: 20 cpm

TEMP: 98.3 F

SPO2:98% on RA

GRBS: 164 mg/dl

P:

NBM till further orders

INJ. MEROPENEM 500mg IV BD (Day 10)

INJ. COLISTIN IV OD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

DAY 11

SOAP NOTES ICU BED-6, DAY -11

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 120/80 mmHg

HR:98 bpm

RR: 20 cpm

TEMP: 100.8 F

SPO2:98% on RA

GRBS: 175 mg/dL

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting hrly

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000

DAY 12

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 110/80 mmHg

HR:89 bpm

RR: 20 cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 148 mg/dL

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting hrly

Day 13:

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 110/80 mmHg

HR:86 bpm

RR: 20 cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

Tx:

IVF - 10 NS 10 RL

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS 4 units given 

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Day 14- 

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 110/80 mmHg

HR:88 bpm

RR: 20 cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

 

Tx:

IVF - 10 NS 10 RL

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS 4 units given

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Added: tab orofex -xt /PO/ OD

Inka. Erythropoietin once weekly.

Day 15- 

 

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 110/80 mmHg

HR:87 bpm

RR: 18cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS 4 units given

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Inj. IRON SUCROSE 200mg in 100ml/NS IV/OD

 Day 16-

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 100/70 mmHg

HR:88bpm

RR: 18cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

Urology opinion taken

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Inj erythropoietin

Tab orofer-xt /po/od

Day 17:

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 120/80 mmHg

HR:78bpm

RR: 18cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

Urology review and review usg

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Inj erythropoietin

Tab. Orofex -xt /po/od

1 unit of PRBS has been issued

Day 18 - day 20

DOA: 19/05/2022

S:

Previous complaints resolving 

O:

BP: 80/40 mmHg

HR:84bpm

RR: 18cpm

TEMP: 99.7 F

SPO2:98% on RA

GRBS: 159mg/dL

Tx:

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

IV Fluids- NS,RL @ 50mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4 hrly

Inj erythropoietin

Tab. Orofex -xt /po/od

Inj. Lasix  40mg

Test: 

RFT

Urea: 146

Creatitine:5.4

Uric acid : 8.4

Phosphorus : 6.9

Sodium : 134

 Pt. Has been discharged after 20 days of hospital admission