Gen med 2024

 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 


























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