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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