28/m fever since 5 days

28 year old male with c/o fever since 5 days with chills

Pt was apparently asymptomatic 6days back when he developed fever with chills and rigors..high grade

Sudden onset resolved now

2 episodes of vomitings 2 days back, bilious, non projectile, non blood stained

No Malena, hemoptysis, hematemesis

No h/o rash

No h/o loose stools

N/k/c/o DM, htn, tb, ba, Epilepsy

O/e

Pt is c/c/c

TEMP- 99.5°f

Bp- 110/80mmhg

Pr- 81 BPM

RR- 18cpm

CVS- S1 S2 heard

Rs- BAE (+)

P/A- soft non tender

CNS- NFND

Investigations-

DX: Viral Pyrexia with Thrombocytopenia

IVF - ns, RL at 100ml/hr

Inj Pantop 40mg iv od

Inj ZOFER 4mg iv SOS

T. Dolo 650 mg po/sos

Daily postural bp monitoring

Temp charting 4th hrly

60/f with altered sensorium 2° hyponatremia

C/o generalised weakness since 2 months

Body pain (+)

C/o pain abdomen since 8 days

Patient is a diabetic since 20 years initially on OHA later shifted to insulin Mixtard (30/70) since 1 week because of high sugars .

She was apparently assymoptomatic 2 months back ,then she used to complaint of generalised body pains and weakness .

No fever ,no vomitings ,no loose stools.

Since 8 days patient is complaining of pain abdomen - diffuse , intermittently 

No vomitings ,no loose stools .

For the above complaints she was taken to RMP and got symptomatic treatment ,but found to have high sugars ,so they visited local doctor in nalgonda ,where her previous OHA was changed to Insulin.

Now she presented to us with complaints of 

Decreased urine output

Pedal edema , abdominal distension since 3 days .

With decreased food intake ,droswiness

Constipation since 2 days

H/o usage of T. aceclofenac 100mg po od since 3 days

Pt is a k/c/o DM-TYPE2 since 20 years, initially on OHA, since 20 days is on Human Mixtard Insulin (30/70) (30u--x--30u)

N/k/c/o htn, TB, BA, CAD, CVA,thyroid disorders

O/e 

BP- 120/70mmhg

Pr- 81 BPM

RR- 16cpm

TEMP- afebrile

GRBS-319mg/dl

No pallor, icterus, cyanosis clubbing lymphedema. Edema of feet present (grade 2)

CVS- S1 S2 heard

Rs- BAE (+) crepts in left IAA, IMA heard

P/A- soft, distended, umbilicus transversly split, diffuse tenderness

CNS- altered, not oriented to t/p/p

Provisional diagnosis- anasarca

Uncontrolled blood sugars

AKI

Diagnosis-

Altered sensorium 2° to hyponatremia with AKI with ? hepatitis with right renal calculi

With DM-type 2 with uncontrolled sugars

Rx-

IVF- ns, RL up+ 50ml/hr

Inj. Lasix 40mg iv bd

Inj. 3% NaCl @20ml/hr

Inj. Pan 40mg iv od

Inj. ZOFER 4mg iv SOS

Inj. Tramadol 1amp in 100ml NS IV/tid

Inj. Neomol 1gm iv SOS

T. PCM 500mg po/sos

I/o charting

Vitals monitoring

GRBS- 7 Point profile

                  Soap notes (1/1/22)

S- 

O-  BP- 110/70mmhg

Pr- 78 BPM

RR- 16cpm

TEMP- afebrile

No pallor, icterus, cyanosis clubbing lymphedema. Edema of feet present (grade 2)

CVS- S1 S2 heard

Rs- BAE (+) crepts in left IAA, IMA heard

P/A- soft, distended, umbilicus transversly split, diffuse tenderness

CNS- altered, not oriented to t/p/p

A- Altered sensorium 2° to hyponatremia with AKI with ? hepatitis with right renal calculi

With DM-type 2 with uncontrolled sugars

P- IVF- ns, RL up+ 50ml/hr

Inj. Lasix 40mg iv bd

Inj. 3% NaCl @20ml/hr

Inj. Pan 40mg iv od

Inj. ZOFER 4mg iv SOS

Inj. Tramadol 1amp in 100ml NS IV/tid

Inj. Neomol 1gm iv SOS

T. PCM 500mg po/sos

I/o charting

Vitals monitoring

GRBS- 7 Point profile

45 male with SOB at rest

45 male with SOB @rest

HOPI-

Grampanchayat worker came to casualty with c/o SOB at rest since 4 days, anasarca since 4 months

Pt was apparently asymptomatic 2 years back and had h/o chronic alcohol intake- had sudden onset involuntary movements of b/l UL, LL lasted for 15 min and frothing from mouth with uprolling of eyes 

(+) with no post ictal confusion/involuntary micturition/defecation

Taken to a hospital where MRI was done and pt advised to stop taking Alcohol, started on T.Eptoin 100mg po/bd since then.

Then he had episodes of 5-6 since 2 years

4 months back, while he was lying on the bed, he had a seizure and fall from bed leading to fracture of right hip  

Then pt was taken to hospital and said to have low Hb and renal failure. 3 units PRBC tranfusion was done 4 months back and then pt developed pedal edema which was insidious in onset, gradually progressive to anasarca in 4 months

SOB- sudden onset, rapidly progressive with class 4(NYHA classification) with orthopnea and PND

N/c/k/o DM, HTN, BA, CAD, CVA

H/o TB 24 years back, ATT- 6 months

Alcohol addiction since 30 years, last alcohol intake 4 months back

No significant family history

O/E 

TEMP- afebrile

BP- 130/90 mmhg

Pr- 81 BPM

RR- 26CPM

SPO2- 100% at RA

GRBS- 166MG/DL

No icterus, cyanosis, clubbing, lymphedema

Moderate pallor present(+)

B/L pitting type of edema of feet (+) anasarca (+)

CVS- S1 S2 heard, JVP-N

RS- dyspnoe present, b/l crepts (+) in IAA, IMA, ISA

P/A- distended, free fluid (+), bowel sounds heard

CNS- NFND

PROVIONAL DIAGNOSIS-

AKI on CKD with Anemia 2° to CKD with Pulmonary Edema with Metabolic acidosis with seizure disorder with old Right Hip fracture

Dialysis one session done on 30/12/21

1 unit PRBC tranfusion done

Rx:

Fluid restriction <1.5 l/day

Salt restriction <2gm/day

Inj. Ceftriaxone 1gm iv bd

Inj. Lasix 80mg iv/stat--> 40mg iv/bd (8am--4pm--x)

Inj. PANTOP 40mg iv od

Inj.. ZOFER 4mg iv SOS

T. Nodosis 550mg po/bd

Cap Bio-D3 0.25 mcg po/od

T. Orofer-XT po/bd

T. Eptoin 100mg po/bd

Inj. Erythropoietin 4000iu s/c weekly once

Strict I/o charting

Vitals monitoring 4th hrly

1/1/22 

Soap Notes

S - sob reduced compared to yesterday

No fever spikes

O- Pt drowsy, but arousable 

Temp- 99f

Bp- 140/90mmhg

PR- 92bpm

RR- 22cpm

Spo2- 94% at ra

Rs-bae+

Cvs-s1s2+

P/a- soft, bs+

Cns- gcs E3V4M5

2 sessions of hemodialysis done 30/12(Ug 1.5lit), 31/12(Uf 2lit)

A- chronic renal disease with metabolic acidosis

Anemia sec to ? Chronic kidney disease

H/o seizure disorder

Old rt hip fracture

P-Fluid restriction <1.5lt / day

Inj lasix 40mg iv bd

Tab orofex xt po od

Inj erythropoietin 4000sc weekly once

I/o charting

Bp/PR /spo2 charting 4th hrly

3/1/22

DEATH SUMMARY

40/M came to casualty in the state of drowsiness but arousable with anasarca and SOB Grade-4. On presentation to casualty, patient was tachypnic with RR-40CPM, with B/L crepts (+) on all areas of lung fields with hypoxia. Immediately the pt was connected to oxygen and given Inj. Lasix 80mg iv stat, Inj. NTG 1mg in 4ml NS, 3ml IV/STAT given, ABG was done showing severe metabolic acidosis. pt was taken up for emergency dialysis with bood transfusion (as pt was had severe anemia) Pt underwent 3 sessions of dialysis. Dialysis sessions were uneventful. At 4am on 3/1/22, pt becmae unresponsive with fall in saturations adn BP not recordable. Pt was intubated. CPR was initiated and continued for 30 minutes. Despite all efforts, pt could not be revived and was declared dead on 3/1/22 at 4.25am with ECG showing no electrical activity

Immediate cause of death- CARDIO-PULMONARY ARREST SECONDAY TO PULMONARY EDEMA

Antecedent cause- CRF WITH ANEMIA SECONDARY TO CRF WITH METABOLIC ACIDOSIS WITH SEIZURE DISORDER WITH OLD RIGHT INTER-TROCHANTERIC FRACTURE(NON UNION)

68/F with SOB since 3 days

December 27, 2021

This is an 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.  

 

68 year old female patient came with complaints of SOB since 3 days 

HOPI 

Patient was apparently asymptotic 3 years ago then she had shortness of breath and diagnosed with CAD and PTCA was done to LAD 

1year ago she had SOB , angiogram was repeated :triple vessel disease + , but creatinine started to raise and stunting not done 

Patient was admitted and discharged 1week ago for SOB , Acute on Chronic Heart Failure , for which she was prescribed 

Tab.ecosprin gold,

Tab. cardivas 3.125mg,

Tab. Hydralazine 12.5mg,

Tab. Pregabalin 75mg,

Tab. Dytor 10mg ,

Syp. Potchlor 

patient was fine after discharge for 2 days 

Now since 3 days patient had complaints of SOB Grade 4 and pedal edema 

No complaints of decreased urine output, Fever , cough , Facial puffiness .

Past history: 

 K/c/o CAD since 3yrs 

N/k/C/O HTN/ DM / BA 

Personal history: 

Diet - mixed 

Appetite- normal 

Sleep - adequate 

Bowel and bladder movements- regular 

Addictions - no 

GENERAL PHYSICAL EXAMINATION:

Pt is conscious,coherent,cooperative 

Moderately built and nourished

No pallor, icterus, clubbing,cyanosis,lymphadenopathy,edema of feet

Vitals:

Temp-98 F

PR-58 bpm

BP-130/90 mm hg 

Spo2- 64% @ room air

GRBS -98mg/dl 

SYSTEMIC EXAMINATION:

CVS- S1S2 +

RS - BAE+, NVBS+

P/A - soft, non tender , bowel sounds +

Provisional diagnosis:

•Cardiogenic pulmonary edema,

•HFrEF (Ef=36%) secondary to CAD 

Moderate to severe LV dysfunction with severe MR 

? Cardio- Renal syndrome Type 2 

Investigations:

Hemogram  

Hb - 7.8gm/dl 

TLC - 11,600

PlC - 2.86 lakhs /cumm 

CUE : 

Albumin - Nill

Sugars - Nill 

Pc - 2-3 

Ec - 2-4 

LFT: 

TB - 0.69 

DB- 0.26 

SGOT -44 

SGPT - 25 

TP- 6 

ALB- 3.6 

RFT: 

CREAT - 2.5 

UREA - 100 

Na- 146 

K - 5.6 

Cl- 102

Treatment:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

3.nebulisation with duolin,budecort / stat

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

8.Tab B- complex /PO/OD

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

                   28/12/21 (Day 1)

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 82 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HFrEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

3.nebulisation with duolin,budecort / stat

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

8.Tab B- complex /PO/OD

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

                           29/12/21

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 80 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HErEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

7. T. Ultracet po/sos

8.Tab B- complex /PO/OD

8. Syp. Lactulose 5ml po/hs

9.BIPAP intermittently 8th hourly

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

30/12/21

S- sob decreased compared to yesterday

O- Pt c/c/c

BP- 120/70 mmhg

PR- 78 bpm

CVS- S1 S2+

RS- BAE+

CNS- No FND

A- HErEF (EF- 36%) 2° to CAD (POST PTCA-LAD),

Moderate to severe LV dysfunction with severe MR

? Cardio renal syndrome type 2 with cardiogenic pulmonary edema with h/o CAD S/P-PTCA

P:

1. Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. Inj. Lasix 80mg / IV/ stat

2. High flow oxygen@10L/min

4.Inj. Lasix 40mg /IV/BD

5.Tab cardivas 3.125 mg /PO/OD

6.Tab hydralazine 12.5mg/PO/BD

7.Tab ecosprin gold (75/75/20) PO/HS

7. T. Ultracet po/sos

8.Tab B- complex /PO/OD

8. Syp. Lactulose 5ml po/hs

10. BP/PR/Spo2 charting

11.strict I/O charting

12.GRBS 8th hourly

1.Fluid restriction (<1.5L/day), salt restriction (<2.4gm/day)

2. T. Lasix 40mg po/BD

3. T. ultracet po/sos

4. T. Dytor 10mg po/od

5. T cardivas 3.125 mg po/od (2pm)

6. T. Ecospirin gold (75/75/20) po/od (8pm)

7. T. hydralazine 12.5mg/PO/TID (8am--2pm--8pm)

8. T. Orofer-XT po/od

9. T. Nodosis 550mg po/bd

10. T. PANTOP 40mg po/od

11. Syp. Lactulose 5ml po/sos

Dengue NS1 +ve 18/M

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

A 18yr old male patient came to the casualty with 

c/o fever since 6days .

HOPI - 

Patient was apparently asymptomatic 6days back then he developed fever which is high grade , associated with chills and rigors, intermittent , relieves on taking medication associated with headache since 2days, body pains .

Vomiting q episode yesterday, containing food particles, non bilious, non blood stained

Pain abdomen in epigastric region 

No H/o, loose stools , giddiness, hematuria

No rash & bleeding manifestations .

No H/o retro orbital pain , joint pains .

Past History - 

Not a k/c/o HTN , DM,TB, Asthma , CAD, CVD 

Personal history -

Diet - mixed

Appetite - reduced since 2 days

Bowel & bladder movements - regular 

No addictions

Family history - not significant

On Examination 

patient is c/c/c

No pallor , icterus , cyanosis , clubbing lymphadenopathy , edema

Vitals -

Temp - Afebrile 

PR - 102bpm

BP - 100/80 mmHg

RR -14cpm

SpO2- 98%@RA

Systemic examination -

CVS - S1 S2 +VE 

RS -BAE +VE , NVBS +VE 

P/A - soft , non tender , BS +ve 

CNS - NAD 

Provisional diagnosis - 

Dengue - NS1 +ve  

Investigations

Provisional Diagnosis- NS1 POSTIVE DENGUE

Treatment-

IV fluids NS, RL,DNS - 75ml/hr 

T.PCM 650MG /PO/TID 

T.PAN 40MG /PO/OD

T.MVT /PO/OD

20/M Pain abdomen and fever

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

AMC bed 8

 

20year old male came with c/o fever since 4 days and pain abdomen since 1 day 

Pt was apparently asymptomatic 4days back then had fever for 4 days, intermittent, high grade fever, associated with chills and rigors.

Pain abdomen in epigastric region, non radiating throbbing type of pain associated with loss of appetite, not associated with nausea, vomitings, loose stools, constipation, Malena, 

Vomitings 2 episodes, non bilious, non projectile and food as content, watery stools (4-5 episodes), no mucous/blood/dark coloured stools (subsided now)

No h/o Malena, petechiae, hematuria, giddiness, sweating, headache, palpitations, SOB

Pt is n/k/c/o DM, HTN, Epilepsy, CAD, CVA

Personal History:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

No addictions

General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp.-100 F

PR- 91 bpm

BP- 110/70 mmHg

RR- 17 cpm

SpO2- 99% at RA

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+ , NVBS+

CNS- NAD

P/A- Soft, mild tenderness in epigastric region

Investigations- 

24/12/21

SOAP notes

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -97.9 degree f

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 70 bpm

Rr- 15 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

25/12/2021

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -97.9 degree f

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 70 bpm

Rr- 15 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

26/12/21

SOAP 26/12/21

S- c/o pain abdomen reduced

O- patient is conscious coherent and cooperative

Temp -Afebrile

Bp supine : 100/60 mmHg

Standing : 90/60 mmHg

Pr - 68 bpm

Rr- 14 cpm

Spo2 - 98%@ra

CVS - S1 S2 +

Rs - bae + 

P/a - soft ,non tender ,bs + 

CNS - nad 

A- viral pyrexia with thrombocytopenia

P- 

1.ivf -ns with Optinneuron 1 amp iv/of , rl @75 ml/hr

2.inj pantop 40 mg IV/od 

3.inj Zofer 4 mg IV /sos 

4.inj Neomol 100 ml iv/sos

5.tab pcm 500 mg po/tid 

6.temp charting 

7.i/o charting 

8.watch for bleeding manifestations 

Provisional diagnosis- Viral Pyrexia with Thrombocytopenia

Treatment-

IVF- RL, NS @75ML/HR

Inj. PANTOP 40mg IV/OD

Inj. ZOFER 4mg IV/SOS

Inj. NEOMOL 100ml (IV/SOS if temp >100f)

T. PCM 500mg PO/TID

I/O charting

Temperature charting

W/f for bleeding manifestations and postural hypotension