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 



















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