PRE-FINAL ANSWER SHEET

80 year old with complaints of cough, fever, SOB and decreased urine output

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. 

80 year old with complaints of cough, fever, SOB and decreased urine output 

 An 80 year old patient a resident of kurumarthi presented with the chief complaints of 

• cough since 15 days 
• Fever since 15 days

The patient was apparently asymptomatic 10 years back when he developed throbbing  pain in his right meta-tarso phalangeal joint. It was also associated with swelling of the joint and fever. 2 weeks Later he also  had swelling and pain in bilateral knee joints. With these symptoms the patient went to a nearby hospital. On evaluation in the hospital he was informed to have increased Uric acid (as informed by the attender) and was diagnosed with gouty arthritis; treatment was started started for the same (drugs taken- unknown). He was diagnosed with CKD during this visit. 

During the same visit he was diagnosed with hypertension and medication was given.(stamlo 2.5mg OD). He has been compliant with the medication till date. 

After 2 weeks of using the medication for gouty arthritis the patient symptoms increased and progressed to involve his bilateral hip joints, shoulder joints, MCP, DIP and PIP. After which he stopped the medication prescribed to him and switched to homeopathic medication. 

His symptoms subsided with the prescribed homeopathic medication and he was compliant with them.  

He used to have exacerbation of the gout when he consumes red meat or any pulses. He  used to have 2 exacerbation in an year, during these episodes he used to take a higher dose of the homeopathic medication. 

The patient stopped working in the field due to his severe symptoms. 

Over the course of 10 years the patient’s lifestyle was severely effected. He started using a stick to help him walk 8 years back and started using a four legged stand 6 years back. 

He stopped using homeopathic medication 3 years ago as his symptoms of pain and swelling in the joints reduced. During the episodes of exacerbations, he used to take a paracetamol which relieved his symptoms. 

• The patient complains of cough since 15 days. It was associated with sputum which was profuse, viscous, pale-yellow coloured, non- blood tinged and non-foul smelling. There is no diurnal and positional variation.  
• He has had high grade fever since 15 days which is not associated with chills or rigor. 
• He also complains of shortness of breath since 15 days. Which initially started as grade 2 MMRC  classification (shortness of breath after walking 100m) later progressed to grade 4 MMRC classification (shortness of breath at rest). He didn’t have orthopnea, paroxysmal nocturnal dyspnea, chest pain and palpitations.There were no aggravating  or relieving factors as such. 
• He has decreased urine output since 3 days. 

The patient was taken to an hospital in Hyderabad 8 days back where he had one round of dialysis ( reason for dialysis: unknown. According to the attender the creatinine was high) 

He later came to our hospital for further dialysis. 

PERSONAL HISTORY :

He take a mixed diet, his appetite has decreased since the past 15 days.

His bowel movements are regular 

He has decreased urine output. 

His sleep is disturbed due to cough. 

He used to smoke 20 chutas/ day. He started smoking at the age of 17.  He stopped smoking after being diagnosed of gout 10 years back. 

He consumes alcohol occasionally (30ml whiskey)

He doesn’t have any know food allergies or drug allergies 

FAMILY HISTORY:

No history of coronary vascular diseases, cancer, epilepsy, cerebral vascular diseases. 

GENERAL EXAMINATION:

Patient is drowsy and easily arousable. 

Moderately built and poorly nourished

Pallor is present 

Mild bilateral pitting type of pedal edema is present

No icterus, clubbing, cyanosis, generalised lymphadenopathy is seen 

 

 

VITALS:

PR: 82bpm

BP: 110/80 mmHg

RR: 20cpm

Temperature: Afebrile

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM : 

INSPECTION: 

 bilaterally symmetrical 

Expansion of chest: Decreased on left side

Position of trachea: Central

Supraclavicular and infraclavicular hollowness seen

Spinoscapular distance could not be measured

Muscle wasting seen over supraclavicular area

Crowding of ribs seen

Retraction of intercostal muscles seen on respiration 

No visible scars, sinuses, pulsations

PALPATION:

Inspectory findings confirmed

No tenderness, local rise of temperature

Decreased expansion of chest on left side in all areas

Chest diameter: AP- 27cm ; Transverse- 23cm 

Position of trachea: Central

Vocal fremitus: resonant note felt

PERCUSSION:

Dull note heard over Left infraclavicular, mammary and inframmary areas

Posterior side not percussed

Other areas- resonant note heard

AUSCULTATION:

Bilateral crepts heard over mammary, inframmary areas

Decreased breath sounds bilaterally

Vocal resonance: resonant in all areas

CVS: 

On palpation,

-Apex beat felt at 5th intercostal space along midclavicular line

-JVP not raised

-No precordial bulge 

-No parasternal heave

On percussion, the heart borders were in normal limits   

On auscultation, S1, S2 heard; no murmurs

P/A:

Soft, non-tender

No hepato-spleenomegaly noted

CNS: 

HIGHER MENTAL FUNCTIONS- 

Altered sensorium seen

Drowsy and (?)

Speech and language normal

Memory intact

CRANIAL NERVES-

1, 9,10,11, 12: Could not be elicited due to O2 mask

Other cranial nerves are normal

MOTOR EXAMINATION- 

Normal bulk in upper and lower limbs

Normal tone in upper and lower limbs

Normal power in upper and lower limbs

Gait could not be examined

SENSORY EXAMINATION-

Normal sensations felt in all dermatomes

REFLEXES-

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited.

CEREBELLAR FUNCTION-

Normal function

No meningeal signs were elicited. 

EVALUATION: 

 

Fever chart 

RENAL FUNCTION TEST:

X- ray chest 

LIVER FUNCTION TEST: 

Hemogram: 

Treatment plan : 

Day 1 of hospitalisation:

10/1/22

P:

TREATMENT GIVEN 

INJ.PAN 40 MG /IV/OD 

INJ.ZOFER 4 MG /IV/SOS 

IVF - NS @ UO+50 ML/HR 

INJ .LASIX 20 MG /IV/BD 

TAB PCM 650 MG /RT/SOS 

INJ PIPTAZ 2.25 G /IV/TID 

BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS CHARTING 12 TH HOURLY 

2nd hourly oral suctioning

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. 

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. 

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.