Gen Medicine Case Study

Under the guidance of INTERN PRAKASH SIR

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.

 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case 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.

CASE SCENARIO :

Unit 4 admission

- A 45year old female resident of halia came to the casualty with the complaints of 

- Fever since 5days

- Vomitings from the afternoon at around 12pm

- Altered sensorium from afternoon at around 6pm

History of Present illness :

- Patient was apparently asymptomatic 15 days back with her daily routine work then suddenly at around evening she complained of burning micturation along with abdominal pain for that she took medication from RMP and it was not subsided, and 5 days back she had a fever which is continuous and subsided when patient took the medication.Again she had a fever continuosly, on Thursday at around 12 pm she had a vomiting (3 episodes) which is on her bed only,which was non bilious,non projectile,non blood tinged,with food particle and she had a stools which are passed on her bed .One of her neighbour saw the patient and informed to her relatives.Her relatives took the patient to local hospital in auto. On the way of reaching the hospital she was talking with the relatives. After reaching the local hospital they had done some routine investigations and confirmed it as a dengue positive.In the hospital ,she became drowsy the doctor refferd to higher centre for better treatment.Then they came to Kims hospital narketpally.By asking,her husband told that she was completely alright 14 years back then her menstruation ceased.After that she was completely alright,then she had a trauma on her left leg,and the leg swollen for that she took pain killers from RMP continously for 1 month. After 3 days of that trauma she had abdominal pain,all this events occured in the month of December 2020.One day in the same month she again had a severe abdominal pain,went to another local hospital and diagnosed with cervical cancer,and they refer to higher hospital in Hyderabad where they done hysterectomy in Feb 2021.

History of Past illness :

No history of DM, HTN, Asthma, TB.

Pupillary Reflex - NSRL

PROVISIONAL DIAGNOSIS :

Altered Sensorium Secondary to Dengue Encephalities.

NS 1 Positive dengue

With multiple infarts in Right thalamus

B/L Cerebellum

With History of Ca Cervix S/P Hysterectomy

With ? Acute viral hepatitis secondary to dengue

INVESTIGATIONS :

3/9/21 -

Haemogram :

Hb - 12.3

TLC - 14900

PCV - 38.0

RBC - 4.53

PLT - 1.10

RBS : 114 mg/dl

LFT :

TB - 2.06

DB -0.78

AST - 498

ALT - 411

ALP - 358

TP - 6.0

ALB - 3.2

PC INR :

APTT - 30 sec

PT - 17 sec

INR - 1.22 sec

Blood grouping : B POSITIVE

Rapid dengue : NSI + 

LFT :

Total bilirubin - 2.06mg/dl

Direct bilirubin - 0.78mg/dl

SGOT (AST) - 498 IU/L

SGPT (ALT) - 411 IU/L

Alkaline phosphatase - 358 

Total proteins - 6 gm/dl

Albumin - 3.2 gm/dl

A/G Ratio - 1.15

Serum Electrolytes :

Sodium - 137 mEq/L

Potassium - 4.1 mEq/L

Chloride - 104 mEq/L

Blood Urea - 40 mg/dl

Serum Creatinine - 0.6 mg/dl

Complete Urine examination :

Colour                     -            Pale yellow

Appearance           -             clear

Reaction                  -             Acidic

Specific gravity       -           1.010

Albumin                -                   +

Sugar                -                     Nil

Bile salts               -                Nil

Bile pigments         -              Nil

Pus cells               -               3-6

Epithelial cells         -            2-4

Red blood cells          -          Nil

Crystals.               -                 Nil

Casts                    -                 Nil

Amorphous deposits   -     Absent

Others               -                    Nil 

Haemogram :

Haemoglobin : 12.3gm/dl

Total count : 14900 cells/ cumm

Neutrophils : 85%

Lymphocytes : 10%

Eosinophils : 01%

Monocytes : 04%

Basophils : 00%

PCV : 38.O Vol%

MCV : 83.9 fl

MCH : 27.2 pg

MCHC : 32.4%

RDW-CV : 13.8%

RDW-SD : 42.9 fl

RBC count : 4.53 millions/cu mm

Platelet count : 1.10 lakhs/cu mm

- SMEAR

- RBC : Normocytic Normochromic

- WBC : Neutrophilic leukocytosis

- Platelets : Thrombocytopenia

- Hemoparasites : No Hemoparasites seen

- Impression : Normocytic Normochromic with Neutrophilic leukocytosis And Thrombocytopenia

ECG :

MID BRAIN PLAIN :

2 D Echo :

- No RWMA

- Trivial TR+ , No MR/AR

- Sclerotic AV , No AS/MS

- Good IV Systolic function

- EF 60%

- RVSP 35 mmHg

- No diastolic dysfunction

- No PAH/PE

- IVC size : 1.25 cm

TREATMENT :

- IVF NS,RL,ONS @ 150ml/hr

- INJ MANNITOL 100ml/IO/TID

- INJ PANTOP 40mg IU/OD

- INJ CEFTRIAXONE 2gm IV/BD

- INJ DEXAMETHAZONE 4mg IV/TID

- INJ ACYCLOVIR 400 mg IV/QID

- RT FEED 100ml water hourly, 50 ml milk 2nd hourly

- GRBS 6th hourly

- Strict I/O CHARTING

- BP/PR/TEMP hourly

- SYP LACTULOSE 100ml/RT/ H/S to maintain 2 stools /day

- INJ Vitamin k 10 mg/IV/OD

- INJ LEVIPIL 500mg IV/BD

- NEB  Doulin 8th hrly

              Budecort 12th hrly

              Mucomyst 8th hrly

-  Chest physiotherapy

- Air water bed

- Frequent position change 2nd hourly. 

3/9/21

2 pm 

- IVF 75 ml/hr

- INJ PAN 40mg OD

- FOLEY'S CATHETERIZATION

- RYLE'S CATHETERIZATION

- T PCM/RT/SOS

- GRBS 6th hourly

3/9/21

5 pm

- Pt drowsy 

- GCS- F4V1M4 

- CVS - S1,S2 (+) 

- R/S NVBS (+) 

- P/A soft 

CNS - Tone increased in all limbs

Reflexes :

        B     T      S     A     K             P

R -  3+     3+    3+    -      -       Extension

L -  3+     3+    3+    -      -       Extension

Treatment :

- IVF NS, RL, DNS 150ml/hr

- INJ MANITOL 100ml IV/TID

- INJ DEXA 8 mg IV BD

- INJ CEFTRIAXONE 2gm IV/BD

- INJ ACYCLOVIR 400 mg IV/QID

- INJ PANTOP 40mg IV/OD

- BP/PR/TEMP/RR 4th hourly

- GRBS 6th hourly

- I/O CHARTING

4/9/21

9 am

- Pt is drowsy but arousable with painful stimuli( STU POUR ) , Afebrile

- PR - 79/min

- BP - 180/90 mm Hg 

- CVS S1,S2 (+) 

- R.S BAE (+) NUBS 

- P/A - Soft,NT BS(+) 

CNS 

Doll's eye (+) 

Corneal (+) 

Conjunctival (+) 

Gag Plantar(B/L) 

Pupillary : NS, sluggish to light

5/9/2021

8 am

O/E : E2 V1 M4

Vitals :

- Temperature : 98.6°F

- BP : 140/80 mmHg

- PR : 74 Bpm ( Regular ) @ Volume

CVS : S1S2 heard , no Murmur 

RS : NVBS (+) decreased Breathsounds in (lt) Esa ; B/L Grunting (+) 

- P/A : soft , no Tend Bowel sounds (+) 

GRBS : 169 mg/dl

I/O : 2250/1650 ml

CNS :

  Dolls eye - present 

  Cornea - present

  Conjuctival - present

  Pupils - sluggish

  REFLEXES :

                B     T       S      A      P                       Le

Rt            3+    3+    3+      -       Increased        2+

Lt            3+     3+    3+     -       Increased         2+

 TONE :

                 Rt          Lt

UL.         Hyper     Hyper

LL           Hyper     Hyper

- Didn't pass stools

6/9/21

 8 am 

- Fever spike last night febrile to touch

- Spo2 98% with 2 litres O2

- O/E : E2 V1 M4

- BP : 140/60 mmHg

- PR : 88 Bpm

- CVS : S1 S2 +

- RS : NVRS+

        B/L Grunting

- P/A soft , non tender

- Dolls eye - present 

  Cornea - present

  Conjuctival - present

  Pupils - sluggish

  REFLEXES :

                B    T       S      K       A     P 

Rt           3+    3+    3+    2+      -     Increased

Lt           3+    3+    3+    2+      -      Increased 

TONE :

                 Rt                       Lt

UL.          Increased        Increased

LL.          Increased         Increased