A 36 YEAR OLD MALE WITH EDEMA OF THE THROAT

 Amc bed 1

A 36 year old male patient who is a watchman in a govt. Hospital 1km far from home came to the casuality with swelling of the tongue and uvula.

Hopi:

Patient was apparently asymptomatic before 2007 and then he developed generalized swelling in the body (limbs followed by face) due to which he was admitted in a hospital in miryalguda where trachostomy was done and was referred to our hospital for further management.

Since then he had multiple episodes for which he took hydrocortisone and avil at home and if there was swelling in the face and throat he came to hospital.

Patient develop swellings when exposed to smoke/dust/when he eats certain foods (mutton,fish,brinjal,gongura).

Swellings usually appear 5 to 10 hours of exposure to triggers 

Episodes are more in winters than in summers.

Patient was tracheostomised twice once in 2007 (had generalised edema) and 2016 (swelling of face and throat).

Patient is taking all precautions so he won't have an episode again but he is scared that he will have another episode as he has many triggers and his sleep is disturbed from an year.

Patient also gets the edema when he is stressed if they're any fights or loud voices.

Past history:

Not a k/c/o DM/HTN/TB/BA.

Family history:

No similar family history

O/e:

Patient is c/c/c

No signs of pallor or cyanosis or clubbing or icterus or koilonychia or lymphadenopathy.

Edema of the limbs -ve

Edema of the tongue and uvula present.

Vitals:

BP: 120/80 

PR: 115 

SPO2: 98@ RA

RS: BAE + 

CVS: S1 S2 +

CNS: NFD.

Investigations:

Diagnosis:

Angio neurotic edema.

Treatment:

1. INJ. HYDROCORTIONE 100 MG IV BD

2. NEB with ADRENALINE QID

Treatment advice by ent department:

1. INJ. HYDROCORTIONE 100 MG IV QID

2. NEB with BUDECORT and ADRENALINE

3. Head end elevation.

A CASE OF 40 YEAR OLD WITH FEVER AND SOB AND LEFT LL SWELLING since 3 days

A 30 YEAR OLD MAN WITH STOMACH PAIN AND CHEST PAIN

30 year old man,labour by occupation,came with the chief complaints of

Chest pain from 1 week back

Stomach pain and generalised weakness since 2 months.

 

History of present illness- 

The patient was apparently asymptomatic 1 year back, then he was married and since he was a chronic alcoholic since 15 years age, he used come home drunk after a very tiring day of work and that used to anger his wife and she would leave him for days and because of that he ate at hotels and this went on for many months and which made him take loans which he couldn't pay or compensate and he got beaten up a lot and he has multiple wounds all over his body and face.

One day his wife got pregnant. She was stressed until she couldn't take it anymore and when she was 3 months pregnant she left the house and dint come back yet (now his son is now 3 months old). The in laws wouldn't treat him right and that would frustrate him making him drink more and he used to often fall on the roads unconscious and used be taken home by neighbours who would find him on the streets. 

2 months back he fell from a 10 feet wall and from then he complains of severe pain in the neck.

From 1 month back he c/o generalised body pains dragging type.

Recently 1 week 10 days back he was involved in a RTA and sustained minor injuries over his face and head and tenderness in right side abdomen and back.

For all his complains he went to a private hospital where he spent 70000 (stressed by the patient) and all the tests were done and it showed e/o infection of the gall baldder.

He complains of Chest pain since 1 week and also increased frequency of vomitings from 1 week and productive cough since 2days.

Past history : 

No h/o DM, HTN, TB, BA, Epilepsy and thyroid abnormalities.

Family h/o: 

No similar complaints in family 

No h/o DM, HTN, TB, BA, Epilepsy, CVA, CAD.

Personal h/o: 

       Diet- mixed    

       Appetite-reduced

       Sleep- not adequate 

       Bowel and Bladder movements- Regular

       Addictions: consumption of alcohol (beer)since age 15.

O/e: General Examination:

Patient is C/C/C

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

Vitals:

Temp - afebrile.

PR- 90 bpm

BP- 150/90 mmHg

RR- 14 cpm

SpO2- 98% at RA

Investigations:

Treatment:

1. INJ. PAN 40 MG IV OD 

2. INJ. ZOFER 4 MG IV BD

3. INJ. OPTINEURON 1 AMP IN 100 ml NS IV OD

4. INJ. LORAZEPAM 1 AMP/ 4 MG IM 

5. IVF NS and RL at 75 ml/hr

6. INJ. THIAMINE 1 AMP in 100 nl NS  IV TID

7. TAB. LIBRIUM 25MG  for 2 days 

1.....1.....1.....2

8. TAB BACLOFEN XL 20 MG for 2 days 

1.....X.....1

9. Tab PCM 650MG PO SOS

A 70 year old female with fever and left sided chest pain

A 70 year old female came to casuality with c/o fever since 1 day. Left sided chest pain since yesterday night and vomiting since today morning (1 episode) at 4 am.

She was apparently asymptomatic 1 day back and then she developed fever, lowgrade, continuos relieved on taking medication. Not associated with chills and rigors

Left sided chest pain non radiating, pricking type of sensation to the left hand, associated with sweating, heaviness to the chest and chest tightness present.

Vomitings in the morning at 4am had non projectile, non bilious, contains food particles and non foul smelling.

Past history:

In 2007 she had similar complains PTCA (LCX territory)---> triple vessel disease LCX, RCA CABG done. 

In 2017 similar complaints admitted in NIMS, conservatively treated.

K/c/o diabetes and hypertension since 15 years.

Using vildaglitan 50 mg and metformin 500mg and telma 40 mg.

O: General Examination:

Patient is C/C/C

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

Vitals:

PR- 85 bpm

BP- 130/80 mmHg

RR- 14 cpm

SpO2- 100% at RA

Investigations:

Diagnosis: 

DKA with anteroinferior wall MI (NSTEMI).

Treatment:

1. Inj. HAI 1 ml (40 U) + 39 ml NS  at 8 ml/hr to maintain GRBS less than 200 mg/dl

2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD.

Day 2: 6th jan

S: nausea,generalised weakness

No fever spikes

Pt complaining of chills

Bp :140/90mmhg

PR: 90bpm

RR : 18

Spo2 : 99% at room air

Pt is on insulin infusion since yesterday,

She had 2 episodes of hypoglycemia

Anion gap reduced (31.7 to 21)

Still continuing infusion at 2ml/hr

A: DKA with anterolateral wall MI(NSTEMI) 

K/c/o DM and HTN

Infusion HAI 1 ml (40 U) + 39 ml NS at 8 ml/hr to maintain GRBS less than 200 mg/dl

2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD 

Investigations 

Urea: 71 

Creat: 2.4

Na+ : 134

K+ : 4.8

Cl- : 102

Abg at 6 am

Day 3 : 7th Jan 

 

S: nausea reduced ,generalised weakness

One fever spike @6pm 

Temp 100.6 F 

O : 

Bp :140/80mmhg

PR: 82bpm

RR : 18

Spo2 : 99% at room air

 insulin infusion stopped,

No episodes of hypoglycemia

Input/ output: 1100/1000 ml

A: DKA with anterolateral wall MI(NSTEMI) 

K/c/o DM and HTN

P: started orally 

Bridging of insulin done.. Insulin dose fixed to 10units HAI s/c tid

Plan to shift to amc

1. Inj HAI 10units sc tid

2. IVF. NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD

8. Inj LASIX 20MG IV BD

Investigations 

Na+ : 132

K- : 4.1

Cl- : 99

Abg at 6 am

Day 4
Investigations 

Day 5

Investigations 

Usg abdomen report:

2D ECHO

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