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.

A 40 YEAR OLD FEMALE WITH SHORTNESS OF BREATH AND FEVER

CASE:

A 40 year old female came with the complaints of fever since the past 20 days and shortness of breath since the past 3 days along with vomiting for the past 1 day and decreased urine output for the past 1 day.

Patient was a daily wage worker by occupation. She starts her day at 4am and finishes her morning routine by 6am. She consumes alcohol daily, around 750 ml for the last five years which began after her husband passed away.

HISTORY OF PRESENTING ILLNESS:

- The patient was apparently asymptomatic 20 days ago, when she had an insidious onset of intermittent fever which was low grade, with an evening rise in temperature. This was associated with chills and rigours, and was relieved on taking medications.

The fever was non relenting, so she was admitted to a local hospital in miryalaguda 3 days back where she was given conservative therapy with antibiotics and analgesics, and then she was referred to our hospital 1 day back.

- The patient has been complaining of shortness of breath for the past 20 days. Shortness of breath is present while doing daily activities- Grade 3 (Ex. Washing clothes, cleaning utensils) which gradually progressed and the patient has shortness of breath even at rest (Grade 4). This was not associated with orthopnoea, paroxysmal nocturnal dyspnea or pedal edema.

- The patient has had two episodes of vomiting which are non projectile, non bilious, non foul smelling and contains undirected food particles.

- Patient has had decreased urine output from the past 1 day, associated with burning micturition.

- The patient has visual hallucinations, self and irrelevant talking when under evaluation for the past day.

- No associated abdominal pain, constipation, diarrhoea, melaena.

PAST HISTORY:

Medical history-

The patient is not a known case of Diabetes Mellitus, tuberculosis, asthma, epilepsy, CAD

She had been diagnosed with hypertension 3 years ago, for which she is not on any medication.

Surgical history-

There is no relevant surgical history for this patient

PERSONAL HISTORY:

Diet- Vegetarian

Appetite- Decreased since the past 20 days

Sleep- Decreased since past 20 days

Bowel and Bladder movements- Urine output decreased for past 1 day, bowel movements are normal

Addictions- Patient consumes alcohol daily for the past five years (750ml per day for the past five years)

She experiences sleep disturbances and tremors when she does not consume alcohol

She also has a habit of tobacco chewing occasionally for past 2 years.

Menstrual history-

Age at menarche- 12 years

Cycle repeats every 28 days

She bleeds for five days, uses five pads per day and has no clots

Family history- not significant

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-

INSPECTION:

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

An Ultrasound of the Abdomen was also done, and the positive findings are listed below

- The liver is enlarged, there’s an increase in size along with altered echo texture (extent 17.5cm)

- The spleen is increased in size with a normal echo pattern (extent 13.5cm)

- There is an altered ancho texture of the renal cortex with well maintained cortico medullary differentiation

Patient ECG was done

A Color Doppler 2D ECHO was also done, with the following positive findings,

- There is good left ventricular function

- No regional wall motional abnormalities

- Aortic valve is sclerotic

- The right atrium is mildly dilated

- There is mild diastolic dysfunction

PROVISIONAL DIAGNOSIS-

Fever along with hepatosplenomegaly

Pre renal AKI

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

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

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,