PREFINAL PRACTICAL CASE
Kausalya Varma, MBBS 9th semester
Roll no: 59
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.
I’ve 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.
GENERAL EXAMINATION:
The patient was conscious, coherant, and co-operative and well oriented to time, place and person. With prior consent, patient was examined in a well lit room, lying down on the bed. She in thin built and moderately nourished.
Pallor- Present
Icterus- Present
Clubbing- Absent
Cyanosis- Absent
Lymphedenopathy- Absent
Edema- Absent
Koilonychia- Absent
VITALS-
Temperature- 98.4 F
Pulse rate- 110 bpm
Blood pressure- 110/60 mmHg
Respiratory rate- 36 cpm
Sp02 at room temp- 95%
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION-
Shape – scaphoid, not distended
Flanks – free
Umbilicus – Central, inverted
Skin- LSCS scar is present, no sinuses, striae are seen
Dilated veins – absent
Movements of the abdominal wall with respiration is present
No visible gastric peristalsis or intestinal peristalsis
PALPATION:
Superficial Palpation – No local rise of temperature or tenderness
Deep Palpation-
Liver-
It is palpable in the Right hypochondrium about 5 cms below the Right costal margin in the Mid clavicular line and 2 cms in the midline from the Xiphisternum which moves with respiration and is firm in consistency with a
Smooth surface and a rounded edge. The upper border of the liver is not palpable.
Spleen-
Spleen is palpable in the Left Hypochondrium, enlarging towards the Right Iliac Fossa
2 cms below the Left Costal Margin in the Mid clavicular line, which moves with respiration and is firm in consistency with a Smooth surface and a rounded edge.
Kidney-
It is not palpable
- No other Palpable swellings in the abdomen.
PERCUSSION:
Percussion of Liver for Liver Span- The liver span is 16cm from midclavicular line and 7cm from the sternum, dull percussion
Percussion of Spleen- Dull note in percussion
There is no fluid thrill, shifting dullness
AUSCULTATION:
Bowel sounds are heard
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the fifth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
No adventitious sounds heard
CARDIOVASCULAR SYSTEM-
Inspection-
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated
Palpation-
Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line
No parasternal heave or thrills are felt
Percussion-
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
CENTRAL NERVOUS SYSTEM-
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - Intact
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Superficial reflexes and deep reflexes are present, normal
Gait- Could not elicit, the patient was not able to get off the bed
No involuntary movements
Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated
INVESTIGATIONS
The routine investigations done for this patient include,
12/01/2022
ABG Analysis-
PH- 7.40
PC02- 21.3
P02- 54.7
HC03- 13.0
Serum LDH- 346 IU/L
LFT-
Total bilirubin- 4.7 mg/dl
Direct bilirubin- 2.57 mg/dl
AST- 102
ALT- 35
ALP- 144
Total proteins- 5.6
Albumin- 2.3
A/G- 0.72
RFT-
Urea- 45 mg/dl
Creatinine- 3.2
Uric acid- 8.0
Ca- 10 mg/dl
Na- 136
P- 4.4 mg/dl
K- 4.8 meq/lt
Cl- 90 meq/lt
Coagulation profile-
PT- 20
INR- 2.4
aPtt- 41
Complete urine exam-
Albumin- ++
Sugar, bile salts, bile pigments- normal
Pus cells- 10-12
Epithelial cells- 4-5
RBC- 3-4
Casts- granular casts are present
Complete blood picture-
Reticulocyte count- 0.5%
Hb- 5.7
TLC- 18400
N/L/E/M- 93/4/1/2
PLT- 65000
A Fever chart of the patient has been drawn up, as seen below
A Chest X-RAY was done while patient was standing erect and seen in the posterolateral view, as seen below
TREATMENT-
14/01/2022
On observation, the patient is talking irrelevantly and displays agitated behavior.
On examination,
Patient is drowsy and irritable
Grbs:80mg/dl
Bp:110/60mmhg
PR: 94bpm
Spo2: 99%@room air
RR 28
E3 V3 M4
Treatment for
- Cerebral malaria(hepatosplenomagaly)
- Sepsis
- Severe anemia
- Delirium
Treatment-
1.Piptaz 2.25gm/iv/TID
2.Falcigo 120mg/iv
3.Inj zofer 4mg/iv/OD
4.Inj pan 40mg/iv/ OD
5.iv NS (urine output- 30ml/hr)
6. GRBS monitored 6 hourly
12/1/2022
Treatment of Prerenal AKI, UTI
-Clinical malaria (hepatosplenomegaly)
-Sepsis
-Severe anemia (hypo proliferation anemia) evaluation
-Delirium (patient is talking irrelevantly intermittently)
Stools- passed 2 days back
O/E
BP-100/60mg
PR-84/min
CVS-s1 s2 heard
RS- B/L air entry +
CNS-NFD
P/A-soft
Rx
1)IVF 1-NS(urine output+ 30ml/hr)
-RL
2)INJ PIPTAZ 2.25gm*IV*TID
8am-1pm-8pm
3)INJ FALCIGO 120mg*IV
0-12hrs-24hrs-48hrs
4)INJ PAN 40mg*IV*OD
5)INJ ZOFER 4mg*IV*OD
6)GRBS 6th hrly
8am-2pm-8pm-2am
7)strict I/O charting
8)monitor BP/PR/SPo2 chart 4th hrly
9)temp chart 4th hrly
10)syp.cremaffin plus
11)INJ-vit k 10mg/IV stat
12)INJ THIAMINE 1AMP in 100ml NS
Advice-
2d echo
Psychiatry referral
Serum ferritin
24hr urinary protein,creatinine
11/1/2022
Diagnosis-
-Fever hepatosplenomegaly
-Sepsis
-Pre renal AKI
-Anemia (severe)
O/E
Patient is coherent and cooperative
BP-110/60mmhg
PR-84/min
CVS-s1s2 heard
RS -
CNS-NFD
P/A -soft
Hepatospleenomegaly +
GRBS-86mg/dl
Rx
1)IVF ons
Urine output +30ml/hr
2)INJ PIPTAZ 4.5 gm*IV*stat
INJ PIPTAZ 2:25gm*IV*TID
3)INJ PAN 40mg*IV*OD
4)INJ ZOFER 4mg *IV*OD
5)GRBS 6th hrly
8am-2pm-8pm-2am
6)strict I/O charting
7)monitor BP/PR/SPo2 monitoring 4th hrly
8)Tab DOXYCYCLINE 100mg*PO*BD
9)INJ FALCIGO 120mg
Advice-
Arrange for 1 OPRBC
REFERRALS
PSYCHIATRIC REFERRAL
(12/01/2022)
Notes include-
Patient has been evaluated and has a provisional diagnosis of fever and hepatosplenomegaly with pre renal AKI and has been referred to psychiatry due to irrelevant talking, hallucinations for the past 2 hours.
History includes that the patient has had a fever for the past 20 days that is not subsiding. Patient consumes around 6 units if alcohol per day for the past five years, after the death of her husband. She experiences sleep disturbances and tremors when she doesn’t consume alcohol. She also has a history of tobacco chewing. Patient has had similar episodes in the past (5 years back) when she was diagnosed with anemia. Self talking stopped 3 days after starting treatment.
History of the episodes-
As per the attending, and doctors present, she suddenly started talking to the walls as if she was talking to a known person standing in front of her.
She says that she can see them and they are talking objectively about her.
Sleep is disturbed but the appetite is normal.
The case notes of the referral are given below,
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