Wednesday, November 24, 2021

60 YEAR OLD MALE PRESENTED WITH SHORTNESS OF BREATH AND PEDAL EDEMA

 


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 centred 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 60 year old male patient, resident of kakirani (yadadhri district) presented to the OPD with the chief complaints of 

  • Swelling of lower limbs since 4 days. 
  • Shortness of breath since 4 days. 
  • Decreased urine output since 4 days. 
History of presenting illness

The patient was apparently asymptomatic 5 years back when he had episodes of giddiness and had fatigue for which he went to hospital. He was diagnosed with hypertension and was prescribed medication.  He takes his medication regularly and goes of check up every three months. 

3 years back he started experiencing shortness of breath (grade 2: he has to stop for breath when walking at own pace.) due to which he stopped farming and started staying at home since then. 

1 year back, the shortness of breath progressed to grade 3 and he also had complaints of swelling of lower limbs. For these he went to a hospital in Hyderabad where he underwent dialysis. He was referred to our hospital for another session of dialysis after 10 days from then.  After which his symptoms were relived but the SOB was still of grade 2. He was prescribed medication.  

The patient complains of swelling of lower limbs and face since 4 days  It was initially till the ankle later it progressed till the knee in 2 days. 

He also complains of increase in severity of shortness of breath. It was previously of grade 2 now has progressed to grade 3 (sob on walking 100m or doing daily work). He has orthopnea.

 He also complains of decreased urine output since 4 days. He had no burning micturition. 

The patient complains of cough since 3 years. It was productive  since 5 days. The sputum is white in colour, scanty, non foul smelling and non blood tinged. 

No history of fever, palpitations, chest pain, PND, wheeze.

PAST HISTORY 

he is not a known case of DM, bronchial Asthama, epilepsy, Coronary vascular diseases. 

PERSONAL HISTORY

Appetite: normal 

 diet: mixed

Bowel movements: regular

Bladder: decreased urine output since 4 days 

Sleep: disturbed since 2 days due to increase in cough during night 

Allergies: none 

Alcohol consumption: he consumes alcohol during festivals (90ml) but has stopped since 3 years. 


GENERAL EXAMINATION:


The  patient is conscious, coherent, cooperative.

He is moderately built and moderately nourished. 

Edema of the lower limbs was noticed.  It was pitting in nature 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy. 





Vitals:

Temp-98.4 degrees F

BP-130/70mm hg

PR- 73bpm

RR-18cpm



Respiratory system examination

Bilateral air entry was present. Crepts were noticed in all areas. 

On percussion dullness was noticed in left and right infra-scapular areas 

Decreased breath sounds were heard in the left and right infrascapular areas and left infra-axillary area. 


CVS

Apex beat was localised in the 4th intercostal space 1 cm medial to mid clavicular line. 

S1 and S2 are heard. 

No abnormal heart sounds were heard 

JVP was raised. 




CNS:

No fuctional deficits were noticed. 


Per abdominal examination: 

Abdomen is tense. Skin of the abdomen seems thickened 

Shifting dullness is noticed. 

No organomegaly was noticed. 

Thursday, November 18, 2021

60 year old with weakness in the left upper and lower limb


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 centred 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 60 year old male, farmer by occupation and a resident of nalagonda came with the chief complaints of 

  • Weakness in the lower limb since 2 days 
  • Weakness in the upper limb since 2 days 
  • Slurring of speech since 2 days. 
History of presenting illness :

The patient was apparently asymptotic 2 days back. He woke up at 5:00 and did his daily routine. Then he went to milk the buffalo. While he was half way through his work he felt a sudden weakness in the left upper and lower limb; it was sudden in onset with inability to use the left hand. Slurring of speech was also noticed. 

Past history:

There were no similar episodes in the past. 

He was not diagnosed with hypertension, DM, bronchial Asthana, epilepsy, CAD. 

Personal history 

Appetite : normal 

Diet : mixed 

Bowel and bladder: regular 

Addictions: he is consumes alcohol occasionally. (During festivals - 90ml). He does not smoke 

General examination: 

The patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema were seen 

Vitals: 

BP: 130/80mm of hg

PR: 75bpm

Temperature: afebrile 

Respiratory rate: 14cmp 

Systemic examination: 

CNS: 

Cranial nerve examination: 

Right and left cranial nerves 1-10 were intact 

On examination for the cranial nerve 11 ( shrugging of shoulders) the patient was unlable to shrug his left shoulder.

On examination for cranial nerve 12 (protrusion and tongue and it’s movements) : deviation of the tongue to the left side was noticed. 



Motor examination: 

Upper limb: 

                                  Right                      Left 

Tone:                   Normal                    Hypertonic 

Power :         

Biceps                      5                                 4

Triceps                     5                                 4

Supinator                 5                                  1

Palmar interossei     5                                  1

Dorsal interossei      5                                  1

Lumbricals  

Reflexes 

Biceps                   2+                           3+

Triceps                  2+                           3+

Supinator              2+                            3+

Lower limb

Tone                  Normal                  Hypertonic 

Power                    5                                4

Knee                      2+                             3+

Ankle                    2+                              3+


 



Respiratory system examination

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 


CVS

S1 and S2 are heard. 

No abnormal heart sounds were heard. 


Per abdominal examination: 

Abdomen was soft and tender. 

No organomegaly was noticed. 



Monday, November 15, 2021

16 year old female with fever

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 centred 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 16 year old female student, resident of dameracherla presented with the chief complaints of 

  1. Fever since 7 days.  
  2. Dizziness since 2 days. 
  3. Cough since 1 day 

History of presenting illness: 

The patient was apparently asymptotic 7 days back when she had fever. The fever was of high grade, intermittent in nature and was reduced on taking medication(paracetamol ). It was not associated with chills or rigor. On the third day of fever she was taken to the local doctor where tests were done and was told to be typhoid positive. 

She was give injections (unknown) and salines everyday for 3 days. 

As the fever was not decreasing (day6) she was taken to a hospital in dachapally when CBP was done and the patient was told that there was a decrease in blood cells. 

On day 7 of illness, she went to a hospital in Miryalaguda where on checking BP she was told that it was less. 

From there she was shifted to our hospital. 

Since day 2 of hospitalisation, she did not have any episodes of fever. 

Past history: 

-H/o RTA 3 Years ago after which he got implant in right tibia.

-H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound. 

-patient was diagnosed to be sputum + TB and was started on ATT 


Patient complains of dizziness on getting up since 4 days. She takes the help of the attender to go to the washroom as she feels that she might fall down. 


She also complains of cough without sputum since 2 days. It showed nocturnal variation. 


She also complains of swelling of the lower limbs since two days and swelling of the right hand since 1 day. 


Personal history 

 Appetite: normal 

 diet: mixed

Bowel and bladder : regular 

Sleep: adequate 

Allergies: none 



GENERAL EXAMINATION:


The  patient is conscious, coherent, cooperative.

Pallor was seen. Edema  was seen on both the lower limbs till thigh. Right upper limb showed edema. 




No signs of  icterus, cyanosis, clubbing, lymphadenopathy. 




Vitals:

Temp-98.4 degrees F

BP-120/78 mm hg

PR-68bpm

RR-16cpm




Respiratory system examination: 

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 


CVS: 

S1 and S2 are heard. 

No abnormal heart sounds were heard 


CNS:

No fuctional deficits were noticed. 


Per abdominal examination: 

Abdomen was soft and tender. 

No organomegaly was noticed. 





Sunday, November 14, 2021

Internal assesment 1







1 Define bone density, how is it measured? What are the causes, clinical features,diagnosis and management of osteoporosis? (1+2+2+2+3)


https://rishik37.blogspot.com/2021/08/gm-elog-case-7.html




 2 What is myxedema coma? Describe its clinical features , diagnosis and treatment of myxedema coma (2+2+2+4)

http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html(



3 What is the diagnostic approach of young onset hypertension and it’s treatment.

http://keerthykasa80.blogspot.com/2021/09/a-35-year-old-female-with-hypertensive.html(22nd sep, 10:24am)



4 How do you clinically localize the anatomical level of lesion in spinal cord diseases.




5 Causes,diagnosis and treatment of atrial fibrillation.




6 Describe about megaloblastic anemia.
(Shared on 22nd sep, 2:23pm)




7 What are the causes, pathogenesis and differential diagnosis of ascites.

One more Elog shared on 31st aug ,3:39pm)




8 Approach to acute pancreatitis.
(Shared on 22nd sep,1:28pm)




9 Mention the differences in findings between UMN and LMN lesion.
(Discussed on 20th sep 10-11 am class)




10) Indications of hemodialysis.



11) Role of sucralfate in treatment of erosive gastritis?



(Shared on4th sep, 7:48am)


12) Mention the renal manifestations of snake bite?





13) causes of portal hypertension
(Shared on 23rd sep ,12:35pm and discussed during postings)


14 clinical features of Downs syndrome



15) post streptococcal glomerulonephritis complications.
(Shared on 23rd sep, 7:45pm)


16 Causes of cervical myleopathy.
( discussed on 20th sep 10-11am class)







 


Friday, November 12, 2021

A 30 year old male patient with cough, fever, acute urinary retention and ulcers on the leg



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 centred 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 30 year old male,farmer by occupation and resident of Nalgonda came to OPD with the cheif complaints of 

Ulcers on the foot since 1 year. 

Cough since 10 days 

Fever since 10 days

Retention of urine since 5 days 


History of presenting illness: 

The patient was apparently asymptotic 1 year back when he developed a small vesicles on his left leg. It gradually increased in size and was associated with itching. Later several vesicles were seen. It was also associated with swelling of the whole limb and black discolouration of the limb. 

He was then taken to a local hospital where the vesicles were punctured  and he was operated and debridement was done. 

-He gives history of cough with sputum

Since 10 days. The sputum was scanty and had blood tinge and not associated with any foul smell. It didn’t show any positional variation. 

  • he also gives history of fever since 10 days. The fever was low grade fever and showed diurnal variation
  • He has had acute retention of urine 5 days ago,he was able to feel fullness and want to void but couldn't,was put on Foley's outside after which it was removed the next day but he couldn't pass urine and Foley's was replaced


Past history: 

-H/o RTA 3 Years ago after which he got implant in right tibia.

-H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound. 

-patient was diagnosed to be sputum + TB and was started on ATT 


Personal history 

 Appetite: normal 

 diet: mixed

bowel: regular 

Bladder: retention since 10 days. He is put on foleys Cather yet.  

Addictions:  alcohol daily 180 ml since 15 years       

                      smokes 1 pack/day since 15 years. 



GENERAL EXAMINATION:


The  patient is conscious, coherent, cooperative.

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema are seen 


Vitals:

Temp-98.4 degrees F

BP-120/70 mm hg

PR-78 bpm

RR-18cpm

Spo2:97%


Respiratory system examination: 


Inspection: 

shape of chest: elliptical 

Bilaterally symmetrical 

Expansion of chest is decreased on both sides. 

Trachea is central

Apex beat is not seen 

No drooping of shoulders. 

No crowding of ribs. 

No scars are sinuses on the chest.  


Palpation : 

All the inspectory findings were correlated. Apical impulse was felt at the in the 5th intercostal space medial to the mid-clavicular line. 


Percussion: 

Dullness was noted on the suprasinous, supraclavicular infraclavicular and mammary areas on the right side. 

Other areas were resonant. 

Auscultation: 

Decreased breath sounds on the right supraspinous and supraclavicular infraclavicular and mammary areas.Other areas had normal vesicular sounds. 

 

Examination of the ulcer over the left limb:

There are two ulcers which were noticed on the left limb 

  1. Ulcer on the foot: it vertically oval measuring 4*2 cms approximately. The floor of the ulcer shows pus and pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation. 


  1. Ulcer on the leg: it vertically oval measuring 10*3cms approximately. The floor of the ulcer shows pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation. 



Per abdominal examination:

soft,non tender

No guarding or rigidity.

No organomegaly. 


CVS: 

S1 and S2 are heard.

 No abnormal heart sounds were heard 


CNS:

No fuctional deficits were noticed. 


Provisional diagnosis: 

Acute urinary retention under evaluation. 

Pulmonary koch's on ATT since 10 days

Multiple ulcers secondary to TB?








Tuesday, November 2, 2021

18 year old male with high grade fever and vomiting

Tondapu Sreelekha, 9th semester

Roll no. – 135



 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 centred 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. 

 

 

Following is the view of my case: 


CASE


An 18 year old male who is  a student and a resident of Hyderabad presented with the chief complaints of fever since 4 days.  Severe back pain since 4 days.   

Vomiting since 4 days.  

Generalised body pains since 4 days. 

Cough without expectoration since 1 day. 


History of presenting illness 


The patient was apparently asymptotic 4 days back when he developed high grade fever which was sudden in onset and varied between a range of 100-104 without touching the baseline. It was associated with chills and rigor. 

Severe back pain since 4 days. It is so severe that he cries out due to it.  He needs support to get up.  

He has had episodes of vomiting on day 2 and day 4 of symptoms. 

The vomitus contained food particles, it was non bilious and non projectile. 

He has taken Ayurvedic medication on day 3 of fever for the same.

He also complains of pain along SCM. Which aggrevated in touch. 

He has pain while opening of jaw but there is pain while closing it. 



Past history: 


The patient was apparently asymptotic till the age of 5 years. 


2008 (5years)

2/08/2008: diagnosed and treated for typhoid fever.


17/08/2008: He had high grade fever for two days. On the second day as the fever didn’t subside he was taken to the nursing home. While waiting for the doctor he had an episode of seizure. Due to this he was sent to a nearby hospital where he was treated for the same. 

The seizure lasted for 5 mins. Drugs were given when taken to the hospital following which it subsided. Froth from the mouth was present. No history of bladder and bowel incontinence. Postictal drowsiness was present for 10-15 mins. 


He was admitted in the hospital and discharged after 4 days.


Treatment given : Epsolin (phenytoin) it was continued for 1 week post discharge 


No complaints for the next 3 months. 


1/12/2008 

Complains of cough, abdominal pain, watery discharge from nose 

Sudden onset high grade fever with no chills and rigor since morning. 

1 episode of seizure in the evening for 5 mins. Froth from the mouth was present. No history of bladder and bowel incontinence. Postictal drowsiness and confusion was absent. 

Following which he admitted in the hospital. 

He had another episode GTCS at 3am for 5 mins. Froth from the mouth was present. No history of bladder and bowel incontinence. Postictal drowsiness was absent. Tongue biting was observed. 

CRP - raised 

EEG - slow activity 

Treatment given : epsolin (phenytoin), midazolam and diazepam for 5 days. 

Patient was started on sodium valproate 2.5ml BD 


2009  (6 years)


April 2009 

Patient was advised to undergo adeniodectomy and tonsillectomy as it was a underlying cause for febrile seizures. 

7 days post OP 

1 episode of GCTS lasting 1 min followed by 40 mins of postictal drowsiness. Froth from the mouth was present. No history of bladder and bowel incontinence. 

His CRP(1.2mg/dL) and ESR were  raised. 

Treatment: sodium valproate 3ml BD daily. 


2010 (7 years)


June 2010 

1 episode of GTCS lasting for 2 mins. Episode of vomiting during the seizure. Tongue biting was noticed. Froth from the mouth was present. No history of bladder and bowel incontinence. 

CT brain - Normal 

EEG- normal 

Raised ALP:  708U/L

Other LFT were normal 

Sodium valproate serum concentration was observed to be lesser than therapeutic level and thus it’s dosage was increased. 

Treatment : sodium valproate 4ml BD daily 


September 2010 

Patient had abdominal pain for 3 days accompanied with episodes of vomitings and loose motions on the 3rd day 

He was admitted in the hospital 

CBP showed leukocutosis 

LFT showed increased SGOT SGPT and ALP 

Diagnosis given : Anti epileptic medication induced acute gastritis. 



2012 (9 years)

 April 2012 

Patient had moderate to high grade fever since morning following which he had GTCS lasting for 2 mins. Froth from the mouth was present. No history of bladder and bowel incontinence. Tongue biting was seen. 

He was admitted in the hospital for further evaluation 

His serum sodium valproate concentration was noted to be above therapeutic range. 

He was given Tegretol 7.5 ml BD daily and sodium valproate was stopped. 


2013 (10 years) 

July 2013 

He had Abdominal pain for 10 days. On day 11, he had 1 episode of GTCS lasting 2 mins 


Froth from the mouth was present. No history of bladder and bowel incontinence. No tongue biting was seen. 

EEG was normal 

Tegretol was stopped 

Frisium and LEVIPIL  were given for 2 weeks following which levipril was continued. 


No episodes of seizures for 3 years 


2016 (13 years) 


July 2016 

Patient had High grade Fever and multiple episodes of vomiting for 5 days. 

He also had generalised body pain and neck stiffness 

Clinical signs: nystagmus was present. 

Could not  walk in a straight line and could not perform Finger nose test. 

CSF analysis : no abnormality

USG ABDOMEN AND PELVIS : B/L enlarged kidneys with grade 1 renal parenchymal changes. Transient proteinuria was present and was treated for the same. 


2017 (14 years)

July 2017 

High grade fever associated with chills and rigor. It was associated with neck pain which radiated to both upper limbs. 

CSF analysis: no abnormality 

MRI : normal 

CRP : raised 

TLC : raised. 

Diagnosis: AFI with encephalitis 


2018 (15years) 

June 2018 

High grade fever on and off since 1 week. 

Cough, throat pain a generalised weakness since 1 week. 

Admitted to hospital for further evaluation. 

TLC : raised 

CRP : raised 

Proteinuria : 2+ 

Diagnosis given : AFI With acute bronchitis. 


2019 (16 years) 

6 years since the last episode of seizures. 


April 2019 

LEVIPIL dose was tapered. 


July 2019 

Patient had high grade fever with chills and rigor. Diagnosed as AFI with sepsis. 

During this fever episode, the dose of LEVIPIL  was increased as a prophylaxis to prevent the febrile seizures. It was tapered after the fever subsided. 


August 2019 

1 episode of GTCS lasting 2 mins. Froth from the mouth was present. Postictal confusion for 10 mins. No history of bladder and bowel incontinence. Tongue biting was seen. No history of vomiting. 

LEVIPIL dose was increased (500mg BD). It is being used till date. 


2021(18 years) 

February 2021 

Increased frequency of micturition for 2 weeks (day time- 14-15 time night- 4-5 times) frothy urine was observed. 

Cough and cold for 1 week. High grade fever for 5 days. 

Diagnosed with UTI 

Admitted in the hospital and treated for the same. 

24 hour urinary protein was 2488mg/dL

CT abdomen : bulky bilateral renal parenchyma causing partial obliteration of renal sinus fat- likely early pyelonephritis 

Patient was advised a renal biopsy which was not done. 


After discharge the patient was still not relieved of the increased frequency of micturition. 


April 2021 

Ayurvedic medication started for increased frequency of micturition 


May 2021 

Normal frequency of micturition. Ayurvedic medication discontinued. 


Personal history: 

Appetite : decreased for the past 4 days 

Diet : mixed 

Bowel and bladder : normal 

Urine is frothy. 

Sleep : adequate 

Addictions : - 


Family history: 

Father and sister has had an episode of febrile seizure. No further medication was taken. 


General examination: 

The patient was examined after a well informed consent in a well lit room. 

The patient was conscious, coherent and cooperative. He was well oriented to time, place and person. 

He is moderately built and nourished. 

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema were seen. 


Vitals: 

Temperature : 100°C 

BP : 

Rerpiratory rate : 18cpm 

Pulse rate : 100bpm 


Systemic examination: 


CNS : intact 

CVS: S1 and S2 are heard. No murmurs we’re heard. 

Respiratory system: BAE+ no adventitious sounds were heard 

Per abdominal examination: soft and no organomegaly was noted. 



Daily routine of the patient 

The patient wakes up everyday at 7:00am. He has breakfast and gets ready to go to college. He travels to his college by bus. He attends his college from 9:00am to 3:00pm. He comes back home by bus. From 4:00pm to 6:00pm he freshens up and takes rest. At 6:00pm he goes to attend Tutions for an hour after which he comes back home and completes his homework. He has dinner at 9:00pm and sleeps at 10:30pm 





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