1801006069 - LONGCASE
This is an 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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.
I have 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
MED CASE:-
A 50-year-old male patient farmer by occupation came to the casualty with the
Chief complaints:-
- shortness of breath for 10 days
- complaints of edema in both upper and lower limbs for 6 days
- decreased urinary output for 6 days
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic till 2008; then he fell down from a tree while working in the field and he developed Backache which was persistent and relieved on rest (he did not use any medication for a year). After a year he used started using medication ( painkillers as said by the patient drug unknown; dose unknown; which relieved his pain but he stopped going to work.
In 2016; the patient started having shortness of breath grade 2 and a high fever with chills and rigor, relieved by taking medication.
There was a history of dizziness and he was taken to a local government hospital where he was investigated and found to have
DM - type 2 for which he was prescribed
Metformin( dose - 500mg; no side effects are seen due to drugs) and he used them regularly with regular diet management and mild exercise.
In a private hospital And was referred to our hospital for further management.
PAST HISTORY:-
DM since 6 yrs ( metformin is used 500 mg)
TB 3 yrs ago .
Not a known case of; Hypertension, thyroid,or Asthma.
No history of any surgeries in the past.
Drug history:- intermittent use of NSAIDS for the past 14 years.
PERSONAL HISTORY:-
Diet - mixed
Appetite normal
Sleep - adequate
Bowel - regular; decreased urinary output since 6 days
Addictions - occasional alcohol ( Sara) before diagnosing diabetes, after that he stopped for some years and again started occasional alcohol for 2 years
Cigarettes stopped 25 years back before 1 pack per year.
FAMILY HISTORY:-
no significant family history
ALLERGIC HISTORY:-
no allergies to any kind of drugs or food items
GENERAL EXAMINATION:-
Date of examination:- 17/3/23
50-year-old male patient, supine decubitus who Is conscious, coherent, and cooperative
comfortably lying on the bed, well-oriented to time,
place and person; well built and well nourished
Pulse: 85 bpm
Rate, rhythm(regular)character(normal ), volume - normal
peripheral pulsations [Carotid, brachial, radial, femoral, posterior tibial, dorsalis pedis]- present
no radio radial delay
BP: 120/80 mm Hg measured on Rt Upper arm In the supine position
Respiratory Rate:25 CPM;
type- thoracic abdominal
Temperature:- 96.9 F
SPO 2:- 98 %
GRBS:- 136 mg/dl
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Edema present- bilateral pitting type grade 4
JVP RAISED
Video:-
SYSTEMIC EXAMINATION:-
AP:TRANSVERSE = 5:7
CARDIOVASCULAR SYSTEM:-
INSPECTION:-
Appears normal in shape
Apex beat is not visible
No Dilated veins, scars, sinuses
PALPATION:
1- All inspector findings were confirmed.
2-Trachea is central.
APEX BEAT at 5TH INTERCOSTAL SPACE IN 1 cm LATERAL TO MID CLAVICAL
No palpable murmurs (thrills)
PERCUSSION:-
Heart borders are normal limits.
AUSCULTATION:-
S 1; S 2 heard in ALL THE AREAS
RESPIRATORY SYSTEM:-
INSPECTION:- Chest appears symmetric
No Dilated veins, scars, sinuses
PERCUSSION AND AUSCULTATION:-
PER ABDOMEN:-
no tenderness
no palpable organs
bowel sounds - present
CNS EXAMINATION:-
The patient is conscious.
No focal deformities.
cranial nerves - intact
sensory system - intact
motor system - intact
INVESTIGATIONS:-
7/3/ 23:-
HAEMOGLOBIN %- 10.0 gms %
PCV :- 31.8 vol%
8/3/23:-
HAEMOGLOBIN - 11.3 gms %
PCV :- 36.1 vol%
9/3/23:-
HAEMOGLOBIN %- 11.0 gms %
PCV - 34.5 vol%
SERUM CREATININE - 5.6 mg/dl.
10 /3/23 :-
ULTRASOUND:-
IMPRESSION:- B/L GRADE IN RENAL PARENCHYMAL CHANGES
B/L MODERATE PLEURAL EFFUSIONS
MILD ASCITES
SERUM CREATININE
5.9 mg/dl
SERUM POTASSIUM
3.4 mEq/L
HAEMOGLOBIN % - 10.6 gm
PACKED CELL VOLUME:- 34.2 vol% ( decreased)
11/3/23:-
SERUM CREATININE:- 5.9 mg/dL
Then referred to our hospital
13/3/23 :-
Serology:
HIV: NEGATIVE
Anti-HCV antibodies:- NON-REACTIVE
HbsAg:- NEGATIVE
RANDOM BLOOD SUGAR: 125mg/dl
CUE:- NORMAL
S.UREA: 64mg/dl (N:- 12-42mg/dl)
S. CREATININE: 4.3 mg/dl
S. Na+: 138
S. K+: 3.4 (3.5-5.5)
S. Cl-: 104
CBP:-
Hb:- 12.6 gm/dl
HbA1C: 6.5%
FASTING BLOOD SUGAR:- 93 mg/dl
POST-LUNCH BLOOD SUGAR:- 152 mg/dl
Liver function tests:-
Total bilirubin-0.9mg/dl
Direct bilirubin-0-1mg/dl
Indirect bilirubin-0.8mg/dl
Alkaline phosphatase- 221 u/l
AST-40u/L
ALP- 81u/L
ECG:-
Sinus tachycardia with VPCS .
X-RAY:-
ULTRASOUND:
2D echo:-
Mild LV dysfunction-present
MR +ve, TR +ve (moderate)
USG CHEST:
IMPRESSION:
BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT ) WITH UNDERLYING COLLAPSE.
USG ABDOMEN AND PELVIS:
MILD TO MODERATE ASCITES
RAISED ECHOGENICITY OF BILATERAL KIDNEYS
15/3/22 :-
CBP:-
Hb:- 11.7 Gm/dl
MCH:- decreased
Blood urea:- 140 mg/dl
serum creatinine:- 5.7
Serum electrolytes:- potassium- 3.0 mEq/L
16/3/23 :-
Hemoglobin - 11.4gm/dl
Lymphocytes -18%
PCV - 35.7
MCH - 26.7
RDW-CV - 19.6%
RBC COUNT - 4.27 MILLION/CUMM
BLOOD UREA -191 mg/dl {12-42}
Serum electrolyte
Potassium - 3.1
Serum creatinine 5.7
17/3/2023:-
ECG:-
DIAGNOSIS:-
HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF:45%)
WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)
WITH BILATERAL PLEURAL EFFUSION ( LEFT > RIGHT )
WITH MODERATE ASCITES
WITH K/C/O DM II FOR 6 YEARS
WITH OLD PULMONARY KOCHS(3 YEARS AGO)
TREATMENT:-
1. Fluid Restriction less than 1.5 Lit/day
2. Salt restriction of less than 1.2 gm/day
3. INJ. Lasix 40 mg IV / BD
4. TAB MET XL 25 mg
5. TAB. CINOD 5 mg PO/OD(IF SBP MORE THAN 110 mm HG)
6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)
7. INJ. PAN 40 mg IV/OD
8. INJ. ZOFER 4 mg IV/SOS
9. Strict I/O Charting
10. Vitals Monitoring
11. TAB. ECOSPRIN AV 75/10 mg PO
12. INJ. ERYTHROPOIETIN 4000 IU SC/ONCE WEEKLY
13. T.SODOCEL 500 mg/PO/TLD
14. SYP. POTKLOR 15 ml PO/TID
8AM_2PM_8PM
Consent form:-
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