A CASE OF 80 YEAR OLD MALE PATIENT

A 80 year old male brought to casuality with c/o constipation since 20 days (on and off).

Not passing stools and Flatus since 5 days 

Shortness of breath since 5 days.

History of presneting illness:

Patient was apparently asymptomatic 3 years back and then he developed pain abdomen in epigastrium localized and not a/w nausea or vomitings aggravated after food intake.

Since 1 year patient complains that he used to wake up in the middle of night and felt breathless for a while. Since 20 days patient history of generalised weakness with loss of appetite and has constipation with small quantity of hard stools. Sinec 5 days patient complains he didn't pass stools and flatus which makes him discomfort associated with pain abdomen.

Personal history:

Patient lost his appetite since 20 days and disturbed sleep.

Addictions: H/o Smoking (Sutta) since 55 years. chronic alcoholic drinks 90ml whiskey daily.

General examination:

Patient consious, coherent, cooperative.

No signs of icterus, clubbing, lymphadenopathy, edema

Signs of pallor.

Vitals: 

Temp: afebrile

Pr: 90 bpm

Rr: 20 cpm

Bp: 130/80 mmhg

Spo2: 98%

Grbs- 132 mg/dl

Systematic examination:

CVS: S1 and S2 heard

RS: BAE + 

CNS: NAD

P/A: soft , tender.

Fever chart.

Diagnosis:

Constipation 2to ?Uremic gastroparesis with RCA territory Akinesia (?old MI).

Investigations on 10/12/21:

Hemogram:

Hb- 11.5

Tlc- 29,300

Plt count- 1.62

RFT:

Urea- 202

Creatinine- 5.9

Na+- 137

K+- 4.5 

Cl-- 90

LFT:

ALP- 437

ALB- 2.8

CUE:

ALB +

RBC - Absent.

ABG:

Ph- 7.473

Pco2- 23.9

So2- 95.6

cHCO3 (P.ST)c- 20.8

cHCO3(p)c- 17.3

Serology- negative.

USG Abdomen

 Chest Xray PA VIEW

xray erect abdomen

ECG

Investigations on 11/12/21

Hb: 11.7

Tlc: 33,450

Plt count: 2.31

Urea: 204

Na+ : 139

K+ : 4.1

Cl- : 96

Spot urine protein: 1.2

Spot urine Creatinine: 100.6

Spot urine Albumin: 0.11

CUE:

Albumin:  +

No sugars 

Ec: 2 to 4

Pc: 2 to 4

Investigations on 12/12/21

Hb: 10.9

Tlc: 22,700

Plt count: 1.59

Blood urea: 203

Serum creatinine: 3.4

Na+ : 144

Cl- : 98

K+ : 3.3

Treatment 

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

2. Inj. PAN 40mg IV BD 

3. inj. ZOFER 4mg IV/SOS

4. Syp. LACTULOSE 20 ml PO/BD

5. Tab.ECOSPORIN 75 mg PO/OD

6. Tab.CLOPITAB 75 mg PO/OD

7. Tab. ATROVAS 10 mg PO/OD

8. Proctoclysis enema twice daily

9. BP/PR/TEMP monitoring 4th hourly.

50 year old female with pain abdomen

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50 year old female with pain abdomen a/w SOB Since 3 days and constipation since 2 days.

A 50 year old female patient came on 30/11/21 with c/o pain abdomen since 3 days a/w sob, constipation since 2 days.

H/o pain abdomen 2 months back

Hopi:

Patient was apparently asymptomatic 3 days back then she developed pain abdomen in right hypochondrium a/w sob grade 2 and 3

H/o nausea and vomiting 4 episodes 3 days back, no palpitations

History of past illness:

N/k/c/o htn/dm

H/o renal caliculi since 2 years managed conservatively.

Examination:

Patient was c/c/c

Temperature: afebrile

PR- 68/min

RR-26min

BP-130/70mmhg 

CVS:s1s2+

R.S:bae +

P/A: Soft, non tender,bs+

Probable diagnosis:

Constipation secondary to Paralytic ileus.

Treatment:

1.IVF- 45% NS @ 75ml/hr

2.Syp. DUPHALAC 10 ml PO BD

3.Tab. BUSCOPAN PO SOS

4.Tab. PAN 40 mg PO OD

5.Soap water enema

6.Monitor vitals 

7.Inform SOS

70 year old female patient

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Unit 5 admission 

A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +

Dry cough since 1 year 

H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided

C/o burning micturition since 2 days 

C/o polyuria since 2 days

C/o biomass exposure since child hood daily

H/o on and off SoB since 10 to 15 years,using RMP medication 

HISTORY OF PAST ILLNESS:

No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures 

Not a k/c/oDM,HTN,CAD,CVA,TB

PERSONAL HISTORY:

Occupation:  house wife

Appetite: lost

Diet: Mixed 

Bowel and bladder movements:  Regular

Allergies: None

Habits: None 

FAMILY HISTORY: 

Not significant.

GENERAL EXAMINATION:

Patient is consious, coherent, cooperative 

Vitals:

Temperature : afebrile

RR: 14 cpm 

Bp:  120/80

HR: 105 bpm

Spo2: 100

GRBS: 131 mg%

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

SYSTEMIC EXAMINATION:

RS: BAE+, Diffuse Wheeze, crepts +

CVS: s1 and s2 heard

P/A: soft, non tender.

CNS: NAD

INVESTIGATIONS:

CBP:

HB:12.3

TLC: 10300

PL: 2.71

CUE:

Albumin and sugars: nil

EC:

PC: 

LFT:

TB: 0.83

DB: 0.20

ALB: 3.8

ALT:  25

ALP: 202

AST: 50

RFT:

UREA: 21

SR. CR: 0.8

UA: 2.0

Na: 141

K: 3.6

Cl: 91

Serology: negative 

ABG:

Ph: 7.443

Pco2: 37.4

Po2: 79.9

So2: 94.5

Hco3(p.st): 25.9

Hco3 pc: 25.2

XRAY:

A 70 YEAR OLD FEMALE PATIENT WITH SHORTNESS OF BREATH

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

Unit 5 admission 

A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +

Dry cough since 1 year 

H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided

C/o burning micturition since 2 days 

C/o polyuria since 2 days

C/o biomass exposure since child hood daily

H/o on and off SoB since 10 to 15 years,using RMP medication 

HISTORY OF PAST ILLNESS:

No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures 

Not a k/c/oDM,HTN,CAD,CVA,TB

PERSONAL HISTORY:

Occupation:  house wife

Appetite: lost

Diet: Mixed 

Bowel and bladder movements:  Regular

Allergies: None

Habits: None 

FAMILY HISTORY: 

Not significant.

GENERAL EXAMINATION:

Patient is consious, coherent, cooperative 

Vitals:

Temperature : afebrile

RR: 14 cpm 

Bp:  120/80

HR: 105 bpm

Spo2: 100

GRBS: 131 mg%

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

SYSTEMIC EXAMINATION:

RS: BAE+, Diffuse Wheeze, crepts +

CVS: s1 and s2 heard

P/A: soft, non tender.

CNS: NAD

INVESTIGATIONS:

CBP:

HB:12.3

TLC: 10300

PL: 2.71

CUE:

Albumin and sugars: nil

EC:

PC: 

LFT:

TB: 0.83

DB: 0.20

ALB: 3.8

ALT:  25

ALP: 202

AST: 50

RFT:

UREA: 21

SR. CR: 0.8

UA: 2.0

Na: 141

K: 3.6

Cl: 91

Serology: negative 

ABG:

Ph: 7.443

Pco2: 37.4

Po2: 79.9

So2: 94.5

Hco3(p.st): 25.9

Hco3 pc: 25.2

PROVISIONAL DIAGNOSIS:

Excarcerbation of COPD

? Viral pneumonia

MEDICINE SHORT CASE

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 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 a diagnosis and treatment plan. 

CASE PRESENTATION:

34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of 

Chest pain since 7 days. 

cough since 7 days.

Shortness of breath since 4 days. 

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 2 months back then developed shortness of breath and chest pain which worsened since 1 week and he had generalised weakness and loss of weight.

Patient had chronic fever since last 6 months which was intermittent and relieved on medication. 

History of cough associated with sputum which was whitish in colour and purulent but moderate amounts since 7 days.

Shortness of breath gradually progressed from grade 2 to 4 associated with chest tightness and difficulty in breathing no complains of palpitation and syncope attacks.

H/o increased hunger and increased frequency of micturition since 6 months which disturbed his daily activities. 

no H/o burning micturition or loose stools and constipation 

No H/o blurred vision or abdominal pains or cramps or loss of consciousness.

PAST HISTORY:

No similar complaints in the past 

Patient was not a known case of diabetes, hypertension, asthma, epilepsy, cardiovascular disorders, Respiratory disorders.

No previous surgical or treatment history.

FAMILY HISTORY:

No similar complaints in the family.

PERSONAL HISTORY:

Diet: Vegetarian 

Appetite: Decreased 

Sleep:  Disturbed

Bowel and bladder movements: Normal 

Addictions:  Alcohol,180-360 ml/day since 14 years and 16-18 beedis per day.

GENRAL EXAMINATION:

Patient is consious, coherent, cooperative and  moderately built and moderately nourished.

He is comfortably lying on the couch.

There are no signs of pallor, icterus, koilonychia, clubbing, cyanosis, lymphadenopathy, edema.

VITALS:

Temperature: Afebrile 

Blood pressure: 90/60 mmHg

Respiratory rate: 27 cpm

Pulse rate: 100 bpm.

SYSTEMIC EXAMINATION:

Respiratory system:

INSPECTION:

• Shape of the chest: elliptical

• Movements: symmetrical bilaterally

• Drooping of shoulders: absent

• Trachea: central

• Apex beat: not seen 

• No presence of any scar, sinuses or dilated veins.

• No use of accessory muscles of respiration

• No Supra or infra clavicular hollowness or fullness

• No drooping of shoulder

• No crowding of ribs 

• No wasting of muscles 

PALPATION:

• No local rise in temperature 

• Slight tenderness on the left 6th intercoastal space.

• All inspectory findings confirmed by palpation.

• Trachea : central- confirmed by three finger test. 

• Chest movements decreased on left side

• Apex beat:left 5th intercoastalspace 1cm to the medial to MCL

• Tactile vocal phremitus -decreased on left infra scapular.

AUSCULTATION:

• Bilateral air entry - present

• Decreased air entry on left infra mammary area, Infra axiallary area and infra scapulary area.

• Wheeze and coarse crepts present.

PERCUSSION:

• dull node is heard on the left Infrascapular area.

• Normal resonant node on the right side.

Cardiovascular system:

• S1 and S2 heard 

• No murmurs 

Per abdomen:

• All quadrants move symmetrically with respiration

• No presence of any scars and sinuses or engorged veins.

Central nervous system examination:

• intact 

• no focal neurological deficits.

INVESTIGATIONS:

On routine investigation:

Chest X Ray:

Ultrasound findings:

Bilateral grade 1 RPD 

Chronic cacific pancreatitis

Minimal ascites

provisional diagnosis:

DKA with consolidation in left lung

TREATMENT:

IVF -- NS and RL  100ml / hr continuos

Inj pantop 40mg /IV /OD

Inj augmentin 1.2gm/IV /BD

Tab dolo 650 mg/PO

Syp- ascoryl -p 10 ml/Po /tid

10ml -10ml - 10ml

GRBS charting 2nd hrly

Inj kcl 2 ampoules 

In 10 NS 

Over 4-5 hours