A 34 year old patient with pain and swelling in the right leg

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: (history as per date of admission)

CASE

A 35-year-old male patient, farmer by occupation  came to the OPD with chief complaints of 

• pain and swelling in right leg since 4 days
• decreased urine output since 4 days

 

HISTORY OF PRESENTING ILLNESS

The patient was apparently assymtomatic 4 days back. Then he felt a prick to his leg while working on the farm land  at 6am which he assumed to be due to a thorn and ignored it and went home. 

After coming back home he noticed that there were bite marks on the leg which were consistent with that of a snake. 

At 9am he went to a local hospital. 

TREATMENT HISTORY 

He was given universal ASV in the local hospital for 3 days. 

H/O 1 PRBC transfusion with 2 SDP transfusion.

He was referred to our hospital for dialysis as his creatinine levels were high (6.1) 

PAST HISTORY

No similar complaints in the past.

He is not a known case of diabetes mellitus, hypertension, TB, Asthma and epilepsy. 

PERSONAL HISTORY

• DIET- non- vegetarian 
• APPETITE- normal
• SLEEP- Adequate
• BOWELS- Regular
• MICTURATION- decreased 
• ADDICTIONS- None
• ALLERGIES- None

GENERAL EXAMINATION

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

He was moderately built and moderately nourished.

·         No pallor

·         No icterus

·         No cyanosis

·         No clubbing

·         No generalized lymphadenopathy

.         He has Edema in the right leg till mid thigh. 

VITALS at the time of admission

·        Temperature: febrile

·        Pulse: 99 beats/mins

·        Blood pressure: 110/80 mmHg

·        Respiratory rate: 18 cycles/min

.        SPO2- 98% at room air

.        grbs-151mg %

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·      Bilateral air entry +

 

CNS- Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

INVESTIGATIONS

22/10/21

24/10/21

X-ray 

ECG

26/10/21

Provisional diagnosis:

AKI 2° to snake bite

?ATN with right lower limb cellulitis

Treatment : 

Day 1 

1 session of hemodialysis for 2 hours along with prbc transfusion

Surgery referral and dressings done for rt lower limb cellulitis 

Day 2 

1 session of hemodialysis done for 2 hrs 

Dressings done for rt lower limb cellulitis

Tab pan 40 mg po/od

Day 3 

Dressing for cellulitis

Tab pan 40 mg po/od

Day 4 

Dressing for cellulitis 

1 session of hemodialysis done 

Tab pan 40 mg po/od 

Day 5 

Planning for dialysis with  transfusion as his hb is 4.9 

Dressing for rt ll cellulitis 

Tab pan 40 mg po/od 

Tab dolo 650 mg /sos 

Tab zofer po/sos 

SYP ASCORYL 10 ml 

Inj optineuron 1 amp in 100 ml NS /IV /OD

A 65-year-old female patient with viral pneumonia secondary to COVID-19

 

Tondapu Sreelekha, 8^th 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: (history as per date of admission)

 

CASE

A 38-year-old female came to the OPD with chief complaints of fever since 10 days and cough since 10 days

 

HISTORY OF PRESENTING ILLNESS

·         Patient was apparently asymptomatic 10 days back when she had fever. It was of high  grade, intermittent and not associated with chills and rigor.

·         She also had cough since 10 days. It was productive and the sputum was of scanty aamount.

PAST HISTORY

·         No similar complaints in the past.

·        She  got a RAT done 5 days back which was negative.

·        She is a known case of hypertension since 7years for which he is taking medication.

·        She is not a known case of diabetes mellitus, TB, Asthma and epilepsy

DRUG HISTROY

·         Tab. NEBIVOLOL 2.5mg/PO/OD

·         Tab. ECOSPRIN AV (75/10)mg

 

 

PERSONAL HISTORY

·         DIET- vegetarian

·         APPETITE- normal

·         SLEEP- Adequate

·         BOWELS- Regular

·         MICTURATION- Normal

·         ADDICTIONS- None

·         ALLERGIES- None

 

FAMILY HISTORY

·         There is no significant family history.

 

 

GENERAL EXAMINATION

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

She was moderately built and moderately nourished.

·         No pallor

·         No icterus

·         No cyanosis

·         No clubbing

·         No generalized lymphadenopathy

·         No pedal oedema

 

 

VITALS at the time of admission

·        Temperature: febrile

·        Pulse: 82 beats/mins

·        Blood pressure: 110/70 mmHg

·        Respiratory rate: 16 cycles/min

·        SpO2: 93% on room air 

SYSEMIC EXAMINATION

 

CVS

·         S1 and S2 heart sounds heard.

·         No murmurs heard.

Respiratory system

·      She patient was dyspnoeic

·      Bilateral air entry +

·     Ronchi were heard.

 

CNS- Intact

Abdomen

·         Soft and non-tender.

·         Bowel sounds were heard.

·         No organomegaly.

 

INVESTIGATIONS (day 1 of hospitalization)

 

INVESTIGATIONS (day 2 of hospitalization)

 

 

Provisional diagnosis: Viral pneumonia secondary to moderate COVID-19 infection.

 

Treatment given (day1)

1.      Tab. PCM 650mg/PO/TID

2.      Syp. ASCORIL 10ml/PO/BD

3.      Neb with BUDECORT – 12^th hourly

4.      O2 inhalation @ 4lit/hr

5.      Plenty of fluids and soft diet.

6.      Tab. NEBIVOLOL 2.5mg/PO/OD

7.      Tab. ECOSPRIN AV(75/10)mg PO/HS

8.      Monitor BP, PR, SpO2 4^th hourly

Vitals (day2)

·        Temperature: afebrile

·        Pulse: 84 beats/mins

·        Blood pressure: 110/70 mmHg

·        SpO2: 96% on room air 

 

Treatment given (day2)

1.    Tab. PCM 650mg/PO/TID

2.    Syp. ASCORIL 10ml/PO/BD

3.    Neb with BUDECORT – 12^th hourly

4.    O2 inhalation @ 4lit/hr

5.    Plenty of fluids and soft diet.

6.    Tab. NEBIVOLOL 2.5mg/PO/OD

7.    Tab. ECOSPRIN AV(75/10)mg PO

8.    Monitor BP, PR, SpO2 4^th hourly

9.    Inj. CLEXANE 40mg/s.c./BD

Vitals (day3)

·        Temperature: afebrile

·        Pulse: 94 beats/mins

·        Blood pressure: 120/70 mmHg

·        GRBS: 8am: 171mg/dL; 4am: 154mg/dL

·        SpO2: 98% on FiO2 40%

 

Treatment given (day3)

1.      IVF 1 NS and 2 RL @ 150ml/hr with THIAMINE and OPTINEURON

2.      Inj. PAN 40MG/IV/OD

3.      Inj. DEXAMETHASONE 8mg/IV/OD

4.      GRBS charting 4^th hourly

5.      Inj. HAI s.c. according to the sliding scale

6.      Vitals charting 4^th hourly

7.      Tab. NEBIVOLOL 2.5mg/PO/OD

8.      Inj. CLEXANE 40mg/s.c./BD

 

Vitals (day4)

·        Temperature: afebrile

·        Pulse: 80 beats/mins

·        Blood pressure: 120/70 mmHg

·        GRBS: 171mg/dL

·        SpO2: 96% on room air 

 

Treatment given (day4)

1.      IVF 1 NS  with OPTINEURON @ 75ml/hr

2.      Inj. PAN 40MG/IV/OD

3.      Inj. DEXAMETHASONE 8mg/IV/OD

4.      GRBS charting 4^th hourly

5.      Inj. HAI s.c. according to the sliding scale

6.      Tab. NEBIVOLOL 2.5mg/PO/OD

7.      Inj. CLEXANE 40mg/s.c./BD

Vitals (day5)

·        Temperature: afebrile

·        Pulse: 74 beats/mins

·        Blood pressure: 110/80 mmHg

·        GRBS: 134mg/dL

·        SpO2: 96% on room air 

 

Treatment given (day5)

1.      O2 inhalation to maintiain SpO2 greater than 90%

2.      IVF 1 NS  with OPTINEURON @ 75ml/hr

3.      Inj. PAN 40MG/IV/OD

4.      Inj. DEXAMETHASONE 8mg/IV/OD

5.      GRBS charting 4^th hourly

6.      Inj. HAI s.c. according to the sliding scale

7.      Tab. NEBIVOLOL 2.5mg/PO/OD

On day 6 0f hospitalization, the patient was found to be stable and fit for discharge.

Treatment advice given at the time of discharge

1.      Tab. NEBIVOLOL 2.5mg/PO/OD

2.      Tab. PANTOP 40mg/PO/BD for 1 week

3.      Tab. ECOSPRIN AV(75/10)mg PO/HS

4.      Tab. LIMCEE PO/OD for 2 weeks

5.      Tab MVT PO/OD for 2 weeks

6.      Tab. APIXABAN 5mg/OD for 1 week

7.      Syp. ASCORIL 10ml/PO/BD for 4 weeks