A CASE OF 47 YEAR OLD ACUTE PANCREATITIS

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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

THIS IS A CASE OF 47 YEAR  OLD ACUTE PANCREATITIS.

C/o pain abdomen since 2 days associated nausea and generalized weakness patient came to psychiatry OPD for de addiction center and was reffered to general medicine OPD in view of pain abdomen.

Patient was apparently asymptomatic 3 days back then he developed pain abdomen, epigastric pain and a/w nausea and generalised weakness.

Past history:

Not a k/c/o HTN, DM, thyroid disorders.

O: General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp - 100 F

PR- 90 bpm

BP- 150/70 mmHg

RR- 22 cpm

SpO2- 98% at RA

Investigations:

Treatment:

1.TAB. PAN 40MG PO OD 

2. TAB LIBRIUM 25MG  1-------X------2

3. TAB LIOFEN  XL 20MG BD

4. TAB NEUBEN PLUS OD x------1-------X

5. TAB THIAMINE PO OD

6. Plenty of oral fluids.

CASE OF 44 YEAR OLD FEMALE with dm,htn and hypothyroidism

"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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

A CASE OF 44 YEAR OLD FEMALE PATIENT WITH HYPOTHYROIDISM, HYPERTENSION, DIABETES.

A 44 year old female came to gm opd for regular check up.

K/c/o dm,htn and hypothyroidism 

History of presenting illness:

Patient was apparently normal before 2004 and then she developed irregular menses for which she went to a local hospital where investigations were sent and treatment was done. The USG reports showed normal ovaries and uterus but presence of gall badder stones (asymptomatic) for which she was operated the same year.

After 2 years she went for a regular checkup and investigations showed e/o hypothyroidism and she's on medication (thyroxine 125mg) Since then.

Next year she was diagnosed as hypertensive (14 years back).

Then after 5 years she went to the hospital as she was feeling very tired and they took her samples and diagnosed her as diabetic 

She is on medication for diabetes and hypertension.

She also c/o of back pain since 12 years I.e; since the birth of the second child (c section I/v/o pre-eclampsia).

In 2019 she went to the hospital again for regular check up and was said to have liver problem

She is also having talengectasia on both legs in the popliteal fossa since 1 year.

Past history:

She is a k/c/o dm,htn, hypothyroidism 

Personal history:

Sleep: disturbed from all the health issue stresses.

Diet: mixed

Appetite: normal

Addictions: none

OBS history:

ML: 23 years

1 st delivery: FTNVD

2 nd delivery: C section i/v/o HTN.

Tubectomised 12 years back.

Family history:

Mother is a k/c/o DM, HTN, arthritis.

And father, k/c/o DM, HTN.

General examination:

Patient consious, coherent, cooperative.

No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals: 

Temp: afebrile

Pr: 94 bpm

Rr: 18 cpm

Bp: 120/60

Spo2: 99% at RA 

Systematic examination:

CVS: S1 and S2 heard

RS: B/L crepts present, IAA

P/A: soft , non tender.

CNS: NAD.

Investigations:

2019

Colour doppler scan report in 2019

Outside usg 

2019

 

2021

Recent usg:

On admission:

Provisional diagnosis:

DM, HTN, Hypothyroidism.

Treatment:

1. T. GIBTULO-MET 12.5/500 MG

2. T. PROPANOLOL 20 MG OD

3. T. OLMEZEST-AM 40/5 MG OD

4. T. THYRONOM 112 MG OD

5. T. HEPTAGON 1 tab BD

A CASE OF 26 YEAR OLD MALE WITH SOB, COUGH AND FEVER

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

This is the case of a 26 year old man.

A 26 year old male presented with c/o SOB, cough and fever since 2 days.

History of presenting illness:

Patient was apparently asymptomatic 2 days back then he developed SOB initially grade 2 now progressed to grade 4 associated with cough, non productive, noy associated with blood.

C/o fever since 2 days.

He had similar complains 4 months back for which he was admitted.

His earliest recall of events dates back to when he was studying in high school ( 9th class ) during the lunch break, he felt severe breathlessness and had to sit back while playing with copious amounts of ?sputum expectoration which he describes it as yellowish in colour and non foul smelling, he describes the incident like he is an old man and needs to sit back to catch up breath 

He continues to feel breathlessness through out his teens and he needs to rest often associated with palpitations on further asking to describe the palpitations it was of pounding nature ( in his words hitting a wall with loud thump ) lasting for 1-2 hours aggravating on lying down 

He often developed respiratory tract infections with history cough with copious amounts of expectorant, sore throat and running nose with is relieving on taking medication ( tab azithromycin). On asking his mother she gave a long history of repetitive infections since childhood once or twice a year and avoiding foods aggravating his cough and cold he was taken to hospital at one year of age for breathlessness

He’s the third born child with term pregnancy  normal vaginal delivery with meconium aspiration and was diagnosed to be dextrocardia on 4th day of delivery as he was sick they were referred to many hospitals and was discharged after relieving his symptoms. 

He was also advised to practice to sit with head low and knees apposed to chest which resulted in vain 

He’s married to his wife and alcohol since two years with occasional binge ( once or twice weekly ) whiskey preferably (90-180ml ) says post binging breathlessness decreases and doesn’t get sputum,he works as an VRO ( village revenue officer ) since after his father was retired and finds it difficult as its not a desk job and halts regularly to catch up breath.

14 days back under the influence of alcohol he had a history of fall from bike 

Sustained head injury with no history of loss of consciousness, ENT bleed and denied going to hospital as he was alright and developed fever on subsequent day subsided on medication

 

History of pedal oedema since 10 days extending upto knee pitting type progressively increasing and attained the present state, he denies history of pedal oedema prior to these 10 days and also denies history of hematuria and frothy urine or decreased urine output and facial puffiness 

3 days back on occasion of raksha bandhan 

Post binge he had 3 episodes of vomiting in the morning was taken to a local doctor revealing potassium 3.2 and creatinine 2.2,TLC -16000 and was given fluids and antiemetic medication 

Since 3 hours he developed breathlessness post binge and was brought to casualty with spo2 41% on RA and 84% on 15L of oxygen

General examination:

Patient is conscious and cooperative 

No pallor, icterus, cyanosis

With clubbing of fingers and pedal edema.

No generalised lymphadenopathy.

Vitals:

Temperature - 97.6

Pulse- 104 bpm

RR- 38 cpm

BP- 90/60 mmHG

SPO2- 60% at RA.

CVS: S1 and S2

RS: B/L crepts IAA and IMA

P/A: Soft and non tender

Provisional diagnosis:

Kartageners syndrome with viral pneumonia

Investigations:

ABG:

PH: 7.35

PO2 : 79.9

PCO2: 53.5

HCO3-: 29.3

St. HCO3-: 26.6

LFT:

Tb: 2.62

Db: 0.62

Ast: 25

Alt: 22

Alp: 170

Alb: 2.2

RFT:

Urea: 37

Creatinine: 1.1

UA: 8.6

Ca2+: 10.2

PO4-3: 4.2

Na+ : 140

K+: 5.5

Cl- : 92

Ecg on 18/12/21:

At 1 am

At 3 am

At 7 am

2D ECHO report

Ecg on 19/12/21

Treatment 
1. Neb BUDECORT  12th hourly

IPRAVENT 8th hourly

2. Inj. LASIX 2O MG IV BD ONLY IF SBP >110 MMHG

3. Inj. PAN 40MG IV OD

4. Inj. DOBUTAMINE 1 AMP in 48 mins at 5 ml /hr 

5. Tab. PCM 650 MG PO SOS 

6. Intermittent CPAP 

7. Inj. NA at 6ml/hr

8. Inj. AUGMENTIN 1.2 gm/ IV BD

9. Tab. AZITHROMYCIN 500MG OD

10. monitoring vitals 

A CASE OF 42 YEAR OLD FEMALE WITH SOB AND COUGH

A 42 year old female patient came to casuality on 15/12/21 with c/o SOB Since 3 months, cough since 10 days,Fever since 7 days and decreased urine output since 2 days.

History of presenting illness:

Patient was apparently asymptomatic 3 months back after which she developed SOB which was insidious in onset (grade 2 to 3 ), progressive in nature a/w Wheeze and orthopnea.

C/o cough since 10 days with expectoration (mucoid, minimal, foul smelling and not blood stained) increased on lying down and decreased when sitting down

- c/o fever since 7 days, insidious in onset a/w chills

- c/o decreased urine output since 2 days 

- No c/o chest pain/ myalgias/ loss of taste or smell/ pnd.

- h/o TB 10 years back ( took ATT for 6 months )

- h/o similar complaints for the past 6 months (on inhalation since 10 days SOS )

- not a k/c/o DM/ HTN/ IHD.

- h/o biomass exposure for 25 years.

Patient was admitted under pulmonology department for the above complains initially where she was intubated ( on 17/12/21) and then was shifted to medicine on 19/12/21 icu i/v/o increased heart rate and 2D ECHO findings.

On 19/12/21 one whole Blood transfusion was done(2 FFP+ 1 PRBC)

2D ECHO findings:

ON 17/12/21

Mild LVH, moderate PAH with RVSP = 70 mmhg

Good LV systolic function and EF=60%

Diastolic dysfunction present and minimal PE 

Dilated RA/RV and IVC.

ON 20/12/21

LAD territory akinetic and mild LV dysfunction (EF=45%)

Moderate TR and PAH (RVSP=65 MMHG)

Dilated RA/RV/IVC

Mild extent MR+

Mild AR +

Sclerosis AS+

Diastolic dysfunction present

General examination

Patient was consious and cooperative

No signs of pallor, cyanosis, clubbing, koilonychia, edema.

Vitals:

Temperature: afebrile

Pr: 120 bpm

Rr: 39cpm

Bp: 140/90 mmhg

Grbs: 141 mg/dl

RS: BAE+ B/L crepts heard at SSA, IAA,ICA,MA

Cvs: s1 and s2 heard

P/A : soft

Investigations on admission: 

Hb: 12.3

Tlc: 24000

Plt. Count: 4.40

LFT:

TB: 1 54

DB: 0.40

AST: 48

ALT: 41

ALP: 351

TP: 7.5

ALB: 3.4

RFT:

UREA: 35

CREAT: 1.0

UA: 7.5

Ca2+ : 10.0

Na+ : 140

K+ : 3.7

Cl- : 92

K+ : 3.7

 

ABG:

PH: 7.32

PCO2: 119

PO2: 67.4

HCO3- : 60.0

St. HCO3- : 52.1

16/12/21

ABG:

PH: 7.34

PCO2: 94.6

PO2: 81.8

HCO3-: 50.3

St.HCO3- : 44.9

Hb: 9.6

Tlc: 14200

Plt count: 3.34

17/12/21:

Na+: 145

K+: 4.2

Cl-: 93

ABG:

PH: 7.35

PO2 : 84.9

PCO2: 77.7

HCO3-: 42.6

St. HCO3-: 38.3

Na+: 145

K+: 3.7

Cl-: 92

Urine for ketone bodies: negative 

Blood urea : 29

Cretainine: 0.6

Ecg:

18/12/21

D dimer:  2650

LFT:

TB: 1.80

DB: 0.40

AST: 58

ALT: 20

ALP: 153

TP: 6.0

ALB: 2.8

Troponin: negative

Blood sugar: 87 (fbs)

CBP

Hb: 9.7

Tlc: 9200

Plt. Count: 2.45 

Bt: 2 min

Ct: 4 min

Pt: 20 sec 

Aptt: 39 sec

ABG:

PH: 7.50

PO2 : 55.4

PCO2: 27.6

HCO3-: 21.5

St. HCO3-: 24.2

Blood group : B positive 

Xray 8 am

xray 11 pm

Ecg at 10 50am

Ecg at 7 20 pm

 

CT:

19/12/21

Hb: 9.2

Tlc: 13800 

plt. Count: 1.57

RFT:

Urea: 44

Creatinine: 0.5

Uric acid: 2.0

Ca2+: 9.2

PO4-3: 2.5

Na+ : 143

K+: 3.5

Cl- : 98

 Ecg at 5 30 am

Ecg at 10 50am 

20/12/21

ABG:

PH: 7.45

PCO2: 46.8

PO2: 198

HCO3-: 32.6

St.HCO3-: 31.8

Ecg:

Provisional diagnosis:

Acute exacerbation of brochiectasis with type 2 Respiratory failiure with PAH with B/L fibrosis with post TB sequelae.

Treatment

1. INJ. PIPTAZ 4.5 GM IV TID

2. TAB. AZITHROMYCIN 500MG OD

3. INJ. HYDROCORT 100MG IV TID

4. INJ. LASIX 20MG IV BD if sbp more than 110 mmhg

5. O2 inhalation at 6 to 8 liters per min

6. NIV with BIPAP continuously with 2 hours gap after meals

7. Neb. With duolin 4th hourly and budecort 8th hourly and mucomist 2nd hourly 

8. Syp. AROSTOZYME 2tbsp TID

9. Syp. ASCORYL 2 Tbsp TID

10. T. PCM 650MG SOS 

11. Inj. PAN 40 mg IV BD

TREATMENT IN MEDICINE DEPARTMENT 

1. 1 WHOLE BLOOD TRANSFUSION 

2. INJ. MIDAXOLAM AT 6 MG/HR

3. INJ. PANTOP 40MG IV OD

4. INJ. PIPTAZ 4.5 GM IV TID

5. T. AZITHROMYCIN 500MG IV BD RT

6. INJ. HYDROCORT 100MG IV BD 

7. INJ  TRANEXA 500MG IV BD

8. INJ. VIT K 10MG IN 100ML NS IV STAT

9. T. SILDENAFIL 20MG RT TID

10. IVF NS RL AT 75 ML/HR

11. AIR/ WATER BED

12. INJ. VASOPRESSIN 1 AMP IN 50 ML NS AT 1.6 ML/ HR 

13. INJ. CLINDAMYCIN 600 MG IV TID 

14. ET SUCTUON + ORAL SUCTION HOURLY.

Soap notes 22/12/21

S - fever spikes+

O- Pt is on mechanical ventilation(intubated on 17/12/21)

Under sedation

Acmv vc mode fio2- 70

Peep- 4, vt- 360, RR- 18,I:E-1:2.3

Temp- 100f

Bp- 120/70mmhg on inj noradrenaline @5ml/hr

Inj vasopressin @0.5ml/hr

PR- 94bpm

RR- 18cpm

Spo2- 97% with fio2-60

Grbs- 160mg/dl

I/o- 1000ml/1100ml

Rs- bae+, inspiratory crepts + at infrascapular and inframammary area

Cvs -s1s2+

P/a - soft ,bs+

Cns - E1VtM1

Pupils - b/l reacting to light

Corneal present

Conjuctival - present

Dolls eye- present

A - acute exacerbation of copd with type 2 respiratory failure 

Severe PAH type 2

Post pulmonary kochs sequale 

Denovo HTN

Heart failure with preserved ejection fraction (ef-45%) 

P- tapering the ionotropes dosage, stop sedation and check for response 

Inj piptaz4.5gm iv tid

Inj clindamycin 600mg iv tid

Inj pantop 40mg iv od

Ivf NS RL @75ml/hr

Neb with ipravent 8thhrly

Budecort 8thhrly

Oral and et suction 2nd hrly 

Chest physiotherapy

A CASE OF 45 YEAR OLD FEMALE PATIENT WITH SOB, FEVER, PAIN ABDOMEN AND GENERALISED WEAKNESS.

A 45 year old female came to the OPD with the C/O Fever since 3 days

HOPI:

Pateiny came with c/o fever since 10 days

Generalised body pains since 10 days 

Pain abdomen since 5 days 

History of presenting illness:

Patient was apparently normal ten days back then she developed fever, low grade associated with chills and rigors not associated with cough, no burning micturiation, no vomitings, no loose stools. Fever subsided after medication 5 days back 

Then since 5 days patient developed pain abdomen around umbilicus and epigastrium, non radiating associated with SOB grade 3 and 4, not associated with nausea and vomiting, loss of appetite

History of past illness:

Not a K/C/O HTN/DM/TB/Epilepsy/Asthma/CAD/CVA

Patient was hysterectomised 15 years ago

Family history - Not Significant

Personal History:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

No addictions

General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp - 100 F

PR- 120 bpm

BP- 90/60 mmHg

RR- 40 cpm

SpO2- 97% at RA

Fever chart:

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+ , B/L IAA, IMA crepts

CNS- NAD

P/A- Soft, Non-tender

Provisional diagnosis:

Viral Pyrexia with Thrombocytopenia, viral pneumonia, sepsis with MODS.

Investigations on admission:

Cue:

Albumin +

Ec : 2 to 3

Pc : 3 to 4

BS : negative

BP: negative

Sugar : negative

Blood cells and casts : negative

Blood urea: 90

Serum creatinine:  1.1

Na+ : 139

K+ : 4.8

Cl- : 95

LFT:

TB: 7.01

DB: 3.10

AST: 111

ALT: 75

ALP: 403

TP: 6.3

ALB: 2.0

ABG: 

PH: 7.37

PCO2 : 53.3

PO2 : 38.1

HCO3- :30.3

ST. HCO3- : 26.7

MP: negative

HIV : Negative

HBSAG : negative

HCV : negative

RAPID DENGUE : negative

RTPCR : negative

Ecg:

2d echo:

usg:

Xray:

Ecg on 18/12/21

Review usg:

Investigations on 19/12/21

Hb: 9.3

Tlc: 20,800

Plt. Count : 3.73

Serum total bilirubin: 9.92

Direct bilirubin: 3.21

Serum creatinine : 0.7

Xray

Plan of treatment 

1. Ivf NS/RL/DNS continuous at 100ml/hr

2. Inj. PAN 40mg IV BD 

3. inj. ZOFER 4mg IV/SOS

4. Inj. NEOMOL 1gm IV/SOS

5. Inj. PIPTAZ 4.5 gm IV TID

6. Tab. PCM 650 mg PO/ SOS

7. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD

8 Tab. TUSQ 1 tab PO BD

9. SYP. ASCORYL-LS 10ml PO TID

10. NEB. IPRAVENT 6th hourly 

NEB. BUDECORT 12th hourly

11. BP/PR/TEMP monitoring 4th hourly 

12. GRBS charting 12th hourly.

13. Intermittent CPAP if not maintaining on O2 

14. Syp. LACTULOSE 10 ml PO TID

A 70 YEAR OLD FEMALE PATIENT

A 70-year-old female Patient came to the OPD with the complains of SOB since 15 days aggravated since yesterday 

Complains of tingling sensation all over the body since 15 days

History of present illness:

Patient was apparently a symptomatic four years back then in January 2018 she developed vomitings SOB chest discomfort went to hospital and diagnosed with CAD(LAD) and was referred to higher Centre -Angiogram was done and stent was placed 

She is on regular medication till two years 

After follow-up, she stopped taking medication and was only taking herbal medication for joint pains 

Two months back she had a similar episode and diagnosed with CAD(RCA) -Angiogram was done, revealed triple vessel disease 

Since 15 days patient had SOB associated with tingling sensation all over the body

 no chest pain 

 no palpitations

 no Pedal Oedema 

Past illness:

 known case of CAD S/P PTCA

No DM/HTN

Personal history:

married Home maker by occupation appetite normal regular bowl and bladder moment no allergies no addictions

No significant family history

General examination :

patient is C/C/C

Pallor

vitals: 

temperature : 97.5°F

Pulse rate : 60 BPM 

Respiratory rate : 18 CPM

BP : 100/70 MMHG 

SPO2 : 98 @ RA

CVS: S1 S2 +

Respiratory system : NVBS+

P/A- soft non-tender

CNS - NO FND

Provisional diagnosis 

k/c/o CAD TVD (post PTCA) 

severe LV dysfunction with ?Cardio-renal syndrome type II

INVESTIGATIONS:

Hb: 8.8

Tlc: 8400

Plt.count: 2.34

CUE:

alb +

Pc: 3 to 4

Ec: 2 to 3

LFT:

TB: 0.96

DB: 0.20

AST: 17

ALP: 132 

ALB: 1.31 

RFT: 

Urea: 71

Creatinine: 2.6

UA: 10.2

Na+ : 146

K+ : 3.1

Cl- : 96

ABG:

PH: 7.55

PCO2: 28.6

PO2 : 72.4

HCO3- : 25.1

ST. HCO3- : 27.4 

SO2 : 94.3

ECG

Plan of Treatment : 

Fluid Restriction 1 L per day

Salt restriction less than 2.4 g per day 

Injection Lasix 40 mg/IV/BD

T. ECOSPORIN-Gold 75/40 MG/PO/HS

T.CARDIVAS 3.125 mg/PO/OD

T.PAN 40 MG/PO/OD (BBF)

T. B-COMPLEX PO/OD 

Strict I/O charting

Monitor vitals hourly