Thursday, August 18, 2022

A 70 year old male with Fever , dribbling of urine,dry cough,myalgia

This is 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 patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 


A 70 year old male patient resident of chityal daily labour by occupation presented with chief complaints of fever since 15 days 
Dribbling of urine since 10 days
Myalgia since 5 days
Dry cough since 2 days


History of presenting illness:
Patient was apparently aymptomatic 15 days back then he had high grade  fever associated with chills ,which is intermittent for which he went to local hospital and took medicine for 7 days,no significant relief from symptoms ,so he went to hospital in Chotuppal and was diagnosed with Typhoid fever.came here for further management.
Dribbling of urine since 10 days associated with burning micturition at times not associated with dysuria ,haematuria.
History of myalgia since 5 days
History of dry cough since 2 days.

Past history:
Patient had complaints of severe low back pain, paresthesia in the lower limbs and sough for consultation and underwent L-S spine fixation 18 yrs back.
He was diagnosed with Diabetes Mellitus on regular health checkup which were conducted in the Health center; and started on Oral hypoglycemic agents since 12 yrs
History of loin pain radiating to the groin on the right side  5 yrs back; treated conservatively.

Personal History:

Non vegetarian.
Sleep was adequate.
Appetite decreased.
Bowel and bladder movements are regular
He used to smoke 12 beedis per day since he was 15 Yrs and stopped 18 yrs back.
He consumes alcohol occasionally since he was 15 Yrs.
No known allergies to drugs.

General examination:

Patient was conscious and coherent.
Pallor: Absent
icterus: Absent
Canosis , clubbing ,lymphadenopathy, bilateral pedaledema absent

Febrile, Temp : 102°F.
PR: 102 bpm; RR: 19 cpm; BP: 110/80mmHg; GRBS: 247 mg/dl.
SYSTEMIC EXAMINATION

CVS: S1, S2+; R/S: BAE+, Clear;
 P/A: Soft, Non tender, BS+,;
 CNS: HMF intact,; NFND.

INVESTIGATIONS:

Chest X Ray PA View:
  X Ray Abdomen and Pelvis ( lateral view)
X ray  Abdomen and Pelvis:




Ultrasound of Abdomen:


Colour Doppler 2D Echo:



PROVISIONAL DIAGNOSIS:
Pyrexia under evaluation


TREATMENT:
1. IVF NS/RL @75 ML/HOUR.
2. INJ. NEOMOL 100ML /IV/TID.
3. INJ. ZOFER 4MG/IV/ SOS.
4. SYP. ARYSTOZYME 15ML/PO/TID.
5. GRBS 7• PROFILE.
6. VITAL MONITORING 4TH HOURLY.
7. I/O CHARTING.





Wednesday, August 17, 2022

A23 year old female with fever ,cough,myalgia since 12 days

This is 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 patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

A 23 year old female resident of Miryalguda home maker by occupation came with chief complaints of fever since 11 days.

HOPI :
Patient was apparently asymptomatic 12 days back.
Then she developed fever for 7 days which was high grade intermittent and associated with chills and rigor
She went to a local hospital and took medication and the fever subsided.
Then after 3 days she again had fever for which she came our hospital and widal test was done and it was negative .
She tested at local hospital and it was positive for dengue and they visited a hospital in Nalgonda and was told her platelet count was low and then they went to Osmania hospital because of some they came our hospital on 14/08/2022

PAST HISTORY:
No similar complaints in the past
Not a known case of Diabetes Hypertension Asthma TB Epilepsy
History of hypothyroidism during third pregnancy and it was normal after delivery
History of Tubectomy and LSCS 3 months back 

FAMILY HISTORY :No significant family history

PERSONAL HISTORY:
Diet mixed
Appetite Normal
Sleep adequate 
Bowel and bladder movements regular
Addictions :No addictions

DRUG HISTORY: No history of allergy to any kind of drugs

 GENERAL EXAMINATION:

Patient was conscious coherent and cooperative
Moderately built and nourished 
pallor present
No, Icterus, Cyanosis, Clubbing, generalized lymphadenopathy
 bilateral pedaledema 

Vitals
Temperature 
RR 20 cpm
PR 90
BP 110/90
GRBS  106gm/dl
Systemic Examination

RESPIRATORY SYSTEM EXAMINATION 
Inspection:
Symmetrical chest 
No scars and sinuses 
Trachea central

Palpation:
Inspectory findings are confirmed

Percussion: 
Resonant note present in all lung areas
Ascultation:
Breath sounds heard. 


PER ABDOMEN 

Inspection: 


No Abdominal distension 

No scars, sinuses, mass visible

Palpation:
Inspectory findings are confirmed 

No local rise of temperature

Tenderness absent

Mild hepatomegaly and mild spleenomegaly


Auscultation
Normal bowel sounds heard
No bruit heard


CARDIOVASCULAR SYSTEM EXAMINATION 

Inspection : Bilaterally symmetrical chest present 

No scars, sinuses

Palpation

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard

No murmurs or additional heart sounds

CENTRAL NERVOUS SYSTEM EXAMINATION 
Higher mental functions intact
Cranial nerves intact 
No focal neurological defecits

INVESTIGATIONS:

DIAGNOSIS 
Dengue fever 

TREATMENT 
Tab Doxy 100 mg PO BD 
Tab DOLO 650 mg PO SOS 
PCM 1 gm IV SOS 
OPTINEURON 1 Ampoule IV OD 
Inj Zofer 
IV Normal saline and Ringer lactate 75ml/hr

Tuesday, August 2, 2022

1801006052short case


This is 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 patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

A 25 year old male patient resident of Yadagirigutta mestri by occupation presented with chief complaints of
Abdominal distension since 6days
Shortness of Breath since 6 days
Yellowish discoloration of sclera since 6days



HISTORY OF PRESENTING ILLNESS:
patient was apparently asyptomatic 4 months back then In April he had fever ,jaundice for 3 days , fever  is not associated with chills and rigor ,no evening rise of temperature he went to hospital , used medication for 1week.
Symptoms subsided  after a week ,he started to consume alcohol(180 ml) daily  since then .

In the month of June he had  Abdominal distension, yellowish decolorisation of sclera , went to a hospital in jangaon took ayurvedic medicine for 1 week , symptoms subsided.

Then he presented on now with complains of Abdominal distension since 6days, Shortness of Breath Gradelll ,fever not associated with Chills and rigor without evening rise of temperature, Altered sleep cycle,facial puffiness,, pedal edema since 3days.
Ascitic tap was done .


PAST HISTORY:
Not a known case of Diabetes mellitus, Hypertension, Epilepsy,Asthma, Tuberculosis, Coronary artery Disease.
No surgeries underwent in the past.


FAMILY HISTORY
 No member of the family has similar complaints.

PERSONAL HISTORY
Appetite- decreased
Diet - Mixed
Bowel& Bladder- Regular
Sleep-Disturbed
Addictions: Alcohol since 10 years  daily 180 ml 
Cigarette 12 / day since 10 years
No known allergies for drugs,food.

GENERAL EXAMINATION:
Patient was conscious, coherent, cooperative poorly bulit and modeately nourished ,
Pallor- cannot be examined due to Yellowish discoloration.
Icterus- present
On the day of admission.
On the next day
cyanosis: Absent
Clubbing: absent
Generalised Lymphadenopathy: Absent
Pedal edema : absent

Vitals:
Temperature
Heart rate:94beats/ min
Blood pressure:118/76 mmHg
Respiratory rate:19 cycles/ min
SYSTEMIC EXAMINATION

Abdomen :
Soft and non tender, Distended.
Inspection: Abdomen distended
 No scars,sinuses.
Umblicus  inverted
No dilated veins

Palpation: All inspectors findings are confirmed Abdomen  is soft and non tender
No visible pulsations
Hepatomegaly
Spleen

Percussion:
Resonant note heard
Shifting dullness present

Auscultation:
Bowel sounds heard.


Respiratory system:
Inspection:
Shape of chest:Barrel shaped
Gynaecomastia present 
A scar present over the rt side
Trachea : central
Wheeze is heard


Palpation:
All inspectors findings are confirmed by palpation
Chest movements: Symmetical
Tactile vocal fremitus
Tidal percussion

Percussion:
Dull note in 6th ICS 
Resonant note in 5th ICS.
Resonant note elsewhere .

Auscultation:
Breath sounds heard.

Cardiovascular system
S1 S2 heard No murmurs.


Central nervous system:
No focal neurological  deficits,all cranial nerves intact .


PROVISIONAL DIAGNOSIS:
Decompensated liver disease with Ascites .

INVESTIGATIONS:
Liver function test:
Prothrombin time:
Activated plasma thromboplastin time:
Renal function test:
Colour Doppler 2D Echo:
ULTRA SOUND OF ABDOMEN:
Ecg:




CHEST X Ray : PA View

Upper GI Endoscopy:


Apraxia Chart:



Ascitic Tap was done on  under aseptic conditions:


TREATMENT:
1. FLUID RESTRICTION.
2. SALT RESTRICTED NORMAL DIET.
3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY.
4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY  INTRAVENOUSLY.
5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.
6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY.
7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY.
8. TAB. PCM 650 mg SOS (<1 GRAM / DAY).
9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.