THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 67 Year old came to casualty with history of involuntary movements of both upper and lower limbs 10 min back ,which lasted for around 2-3 min ,associated with froathing from mouth ,bladder incontinence ,not associated with uprolling of eyes not associated with tongue bite
Post ictal confusion present
H/0 burning micturition since 4-5 days
H/0 hypoglycemic episodes 2 to 3 days back
Not associated with any urgency or frequency
Not associated with any fever
No h/o cough ,cold
No h/o loss of weight, decreased appetite
No h/o nausea, vomiting, abdominal pain
No h/o fatigue, headache
No h/o loss of hair
Past History
K/c/o HTN since 8 -9 years and is on regular medication ( not known )
Past history of TB 15 years ago
N/k/c/o DM 2 , THYROID DISORDERS ,EPILEPSY ,CVA, CAD .
Menstrual history
Patient attained menopause
Family history
Insignificant
Personal history
Marital status : married
Diet : vegtarian
Appetite normal
Sleep : adequate
Bowel and bladder movements regular
No allergies
Addictions - nill
General examination
Patient was in altered sensorium
Moderately built , moderately nourished
No pallor icterus ,cyanosis, clubbing lymadenopathy,edema.
Vitals
BP -120/70
RR - 16/min
Pulse rate - 90bpm
Spo2
SYSTEMIC EXAMINATION
Respiratory examination
Dyspnoea: No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : crepts present in right MA ,AA,IAA, Interscapular area
ABDOMEN
Shape - Scaphoid , inverted umbilicus, no engorged veins, no scars
No tenderness, no palpable mass, No Fluid
No bruits heard
Liver not palpable
Spleen not palpable or any
CNS Examination
Conscious coherent cooperative
No signs of meningitis
Cranial nerves -intact
Sensory system -normal
Motor system -
Tone
Upper limb
Right -normal
Left -normal
Lower limb
Right -normal
Left -normal
Power
Upper limb
Right - 4/5
Left - 4/5
Lower limb
Right - 4/5
Left - 4/5
Reflexes
Biceps Triceps supinator knee ankle
Right +2. + - +2. -
Left +2. +. - +2. -
Plantar reflex
Right flexion
Left extension
Investigations
Anti hcv - non reactive
Hiv rapid test -non reactive
Rbs-137 mg/dl
Cue -
Colour -pale yellow
Apperance -clear
Reaction -acidic
Sp.gravity -1.010
Albumin - +
Sugar- +
Hemogram
Haemoglobin -9.4gm /dl
TLC - 14,700 cells/ cumm
Neutrophils-88
Lymphocytes -7
Eosinophils-1
Monocytes-4
Basophils-0
Pcv-25.5
Mcv-81.4
Mch -29.9
Mchc-36.7
Platelets-2.08
Rft
Urea -42
Creatinine -0.9
Uric acid -2.0
Calcium -10.0
Phosphorous -4.5
Sodium -135
Potassium -4.6
Chloride-99
Hemogram -15/10/24
Haemoglobin -9.7gm /dl
TLC - 12,300 cells/ cumm
Neutrophils-82
Lymphocytes -13
Eosinophils-1
Monocytes-4
Basophils-0
Pcv-28.7
Mcv-86.9
Mch -30.1
Mchc-34.6
Platelets-4.42
Serum electrolytes -15/10/24
Calcium ionized -1.05mmol/L
Sodium -135mmol/L
Potassium -4.6mmol/L
Chloride-101mmol/L
Urine Culture and sensitivity -no bacterial growth
Blood culture and sensitivity -no growth
Mri brain plain
Impression:
Few tiny to small FLAIR hyperintense areas are seen in bilateral frontal deep white matter without diffusion restriction likely s/o chronic microvascular white matter ischemia
. Right mastoid effusion
HRCT OF CHEST
IMPRESSION
Fibrobronchiectatic and fibrocalcific architectural destruction of part of right upper lobe with moderate pleural thickening causing moderate ipsilateral mediastinal shift and tracheal devation ,moderate right hilar upward deviation ,crowding of ribs on the right with mild volume loss of right hemithroax . Multiple sub centrinetric calcified granulomas in right lung.
Few of them are also seen in left upper lobe - suggestive of destructive sequale of old infection
Diffuse mosaic attenuation pattern in left lung -could be small airway disease or mild parenchymal infection
Mild right lower lobe bronchial wall thickening with mild bronchial dilatation .Multiple centrilobular nodules in right lower lobe -s/o reactivation /reinfection
Few subcentrimetric prevascular and right hilar lymphnodes
Mild cardiomegaly
The rib cage ,chest wall and dorsal spine
Dorsal spine shows spondylosis
mild to moderate scoliosis of upper lumbar spine with convexity to left side.
TREATMENT GIVEN:
D1 - INJ LEVIPILL 2GM IV / STAT
INJ . LEVIPILL 500MG IV / STAT
D2 - 6/10/24
1. INFUSION 3% NS @ 25 ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. INJ .PAN 40 MH IV / OD
5. INJ. NEOMOL IGM IV / SOS
6. T. DOLO - 650 MG PO / TID
D3 -7/10 24
INFUSION 3% NS @ 15 ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. T . AZITHROMYCIN 500MG RT /OD
5. T.TOLVAPTAN 15 MG RT / TID
6. T. DOLO - 650 MG PO / TID
D4 - 8/10/24
INFUSION 3% NS @ 50ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. T . AZITHROMYCIN 500MG RT /OD
5. T.TOLVAPTAN 15 MG RT / TID
6. T. DOLO - 650 MG PO / TID
7. INJ. PAN 40MG IV /OD
8. NEOSPORIN POWDER L/A
9. INJ . PIPTAZ 3.375GM IV / QID
10.T. NEOMOL IGM IV/SOS
11. INJ . OPTINEORON I AMP IN 100ML NS IV OVER 30 MIN OD
12. SYP. LACTULOSE POWDER L/A
D5 - 9/ 10 / 24
1.INFUSION 3% NS @ 50ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. T . AZITHROMYCIN 500MG RT /OD
5. T.TOLVAPTAN 15 MG RT / TID
6. T. DOLO - 650 MG PO / TID
7. INJ. PAN 40MG IV /OD
8. NEOSPORIN POWDER L/A
9. INJ . PIPTAZ 3.375GM IV / QID
10.T. NEOMOL IGM IV/SOS
11. INJ . OPTINEORON I AMP IN 100ML NS IV OVER 30 MIN OD
12. SYP. LACTULOSE POWDER L/A
D6 -10/10/24
1.INFUSION 3% NS @ 50ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. T . AZITHROMYCIN 500MG RT /OD
5. T.TOLVAPTAN 15 MG RT / TID
6. T. DOLO - 650 MG PO / TID
7. INJ. PAN 40MG IV /OD
8. NEOSPORIN POWDER L/A
9. INJ . PIPTAZ 3.375GM IV / QID
10.T. NEOMOL IGM IV/SOS
11. INJ . OPTINEORON I AMP IN 100ML NS IV OVER 30 MIN OD
12. SYP. LACTULOSE POWDER L/A
D7-11/11/24
INFUSION 3% NS @ 50ml / Hr
2. INJ . LEVIPILL 500 MG IV / BD
3. INJ . MONOCEF IGM IV / BD
4. T . AZITHROMYCIN 500MG RT /OD
5. T.TOLVAPTAN 15 MG RT / TID
6. T. DOLO - 650 MG PO / TID
7. INJ. PAN 40MG IV /OD
8. NEOSPORIN POWDER L/A
9. INJ . PIPTAZ 3.375GM IV / QID
10.T. NEOMOL IGM IV/SOS
11. INJ . OPTINEORON I AMP IN 100ML NS IV OVER 30 MIN OD
12. SYP. LACTULOSE POWDER L/A
D8 12 / 10 / 24
CONTINOUS BIPAP SUPPORT
D6 INJ . PIPTAZ 3.375 GM IV / QID
INJ . PAN 40 MG
INJ . NEOMOL 1GM
IV
T. TOLVAPTAN 15 MG PO / OD
SYP LACTULOSE 15 ML PO / HS
INJ . OPTINEURON 1 AMP 100ML NS IV OVER 30 MIN
NEOSPORIN POWDER L/A
D9 - 13 /10 /24
INTERMITTENT BIPAP SUPPORT
INJ . PIPTAZ 3.375 GM IV / QID
INJ . PAN 40 MG
INJ . NEOMOL 1GM
IV
T. TOLVAPTAN 15 MG PO / OD
SYP LACTULOSE 15 ML PO / HS
INJ . OPTINEURON 1 AMP 100ML NS IV OVER 30 MIN
NEOSPORIN POWDER L/A
INJ.LEVIPILL 500 MG IV /BD
D10 14 / 10 /24
CONTINOUS BIPAP SUPPORT
D5 INJ . PIPTAZ 3.375 GM IV / QID
INJ . PAN 40 MG
INJ . NEOMOL 1GM
IV
T. TOLVAPTAN 15 MG PO / OD
SYP LACTULOSE 15 ML PO / HS
INJ . OPTINEURON 1 AMP 100ML NS IV OVER 30 MIN
NEOSPORIN POWDER L/A
INJ.LEVIPILL 500 MG IV /BD
D11 14 / 10 /24
INTERMITTENT BIPAP SUPPORT
INJ . PIPTAZ 3.375 GM IV / QID
INJ . PAN 40 MG
INJ . NEOMOL 1GM
IV
T. TOLVAPTAN 15 MG PO / OD
SYP LACTULOSE 15 ML PO / HS
INJ . OPTINEURON 1 AMP 100ML NS IV OVER 30 MIN
NEOSPORIN POWDER L/A
INJ.LEVIPILL 500 MG IV /BD
D12 15 / 10 /24
CONTINOUS BIPAP SUPPORT
D5 INJ . PIPTAZ 3.375 GM IV / QID
INJ . PAN 40 MG
INJ . NEOMOL 1GM
IV
T. TOLVAPTAN 15 MG PO / OD
SYP LACTULOSE 15 ML PO / HS
INJ . OPTINEURON 1 AMP 100ML NS IV OVER 30 MIN
NEOSPORIN POWDER L/A
INJ.LEVIPILL 500 MG IV /BD
PROVISIONAL DIAGNOSIS:
GTS secondary to hyponatraemia secondary to SIADH
? Secondary to paraneoplastic syndrome
Type 2 RF with community acquired pneumonia
Past history of TB 15 years ago
Type 2 bedsore
Known case of hypertension since 4 years
Comments
Post a Comment