MEDICINE CASE DISCUSSION

HELLO GUYS, 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 evidence based input

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 diagnosis and treatment plan.

UNIT 5 ADMISSION 

 32 year old male came to the casualty with clo Pain abdomen in epigastim ,left hypochondrium Since 1 day.

C/o vomiting since 1day (non-billious,non projectile) 2episodes ,containing food-particles

Passing flatus, constipation since 1day morning

Loss of appetite+

No c/o fever

HISTORY OF PAST ILLNESS :

not a K/c/o DM HITN, epilepsy,asthma, CVA,CAD .

PERSONAL HISTORY:

Loss of appetite+,takes mixed diet ,bowel and bladder movements were regular .

H/o alcohol consumption(beer) since 5yrs(2times a day) stopped 1 month back. 

ON EXAMINATION:

Patient  is conscious ,coherent ,co-operative 

Temp-98f

PR-90BPM

RR-20CPM

BP-100/70mmhg

GRBS-266MG/DL

Spo2-98@RA

CVS-S1S2+

RS-BAE+,NVBS

P/A-SOFT,NON TENDER,B/S+

CNS-NAD

PROVISIONAL DIAGNOSIS:

ACUTE PANCTREATITIS SECONDARY TO ALCOHOL

INVESTIGATIONS:

TREATMENT:

1)IVF- NS,RL-150ML/HR

2)INJ.PAN.40MG/IV/BD

3)INJ. THIAMINE 200MG IN 100ML NS /IV/BD

4)INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD

5)INJ.TRAMADOL 1AMP IN 100 ML NS/IV / BD

6)INJ .ZOFER 4MG /IV/BD

7)strict I/O monitoring 

8)BP,PR,SPO2 Monitoring 4th helt

9)GRBS monitoring 6hrly

 SOAP NOTES DAY-2

S: No fresh complaints

Pain abdomen decreased

O:

PR: 82bpm

Bp: 130/80mmhg

Temp: 99F

RR:18cpm

Cvs:s1,s2heard

Rs:BAE+

CNS:NFD 

GRBS :157 mg/dl

A:

Acute pancreatitis secondary to alcohol with denovo diabetes

P:

1)IVF :NS and RL 100 ml /hr

2)INJ pantop 40 mg IV BD

3)INJ.THIAMINE 200MG IN 100ML NS IV/OD (OVER 30MIN)

4)INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

5)INJ.ZOFER 4MG IV/BD

6)INJ.HAI S/C,acc to GRBS

7)BP,TEMP MONITORING

Medicine case discussion

  General medicine case 

HELLO GUYS, 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 evidence based input

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 diagnosis and treatment plan.

Chief complaints:-

A 38 year old female came to casuality with chief complaints of fever and vomitings since 3 days.

History of present illness:-

Patient was apparently asymptomatic  3 days back then she developed fever which is of low grade and associated with chills and rigors and are relived on medication.

Vomting since 3days  of 2episodes daily which was non-bilious and no projectile , containing food particles. History of cold and cough (non productive) were present since 3 days.

No complaint of ‘pedal oedema ,decreased urine output and abdominal distension’.

No complaint of chest pain , palpitations and sob.

History of past illness:-

N/k/c/o HTN, DM, TB, Asthma, CVA, CAD, Epilepsy.

Personal history:-

Marital status:- married

Appetite:- lost

Diet:- mixed

Bowels:- regular

Micturition:- normal

No known allergies.

Family history:- not significant.

Physical examination:-

General examination:-

Patient is c/c/c with moderate build and moderate nourishment 

Pallor:- no

Icterus:- no

Cyanosis:-no

Lymphadenopathy:- no

Malnutrition:-no

Dehydration:-no

Clubbing:- no

Vitals:-

Temperature:- Afebrile

Pulse rate:- 90 bpm

Respiration:-22 cpm

Bp:- 70/50 mmhg

Spo2:- 98%

GRBS:-140 mg/dl

Systemic examination:-

CVS :-s1 and s2 heard,No murmurs.

Rs:-BAE+,NVBS

P/A:-soft and non-tender.

CNS:-No focal deformities.

INVESTIGATIONS:-

Hemogram:-

LFT:-

RFT:-

Serology:- negative

CXR:-

ECG:-

Fever chart:-

Diagnosis:- viral pyrexia with acute gastritis

Treatment given:-

INJ ZOFER 4 mg IV / TID   1-1-1

IVF NS

        RL   @ 100 ml /hr

INJ PAN 40mg IV OD   1-X-X

INJ OPTINEURON 1 amp IN 100 ml NS IV /OD  (OVER 30 mins)    1-X-X

SYP ASCORIL D  10 ml / TID 

10ml  -  10ml  -10ml

ORS

Day 2 SOAP NOTES :-

S-

No fever,cold, vomitings

c/o cough

No fresh complaints

O-

Bp-110/80mmhg

Pr- 86bpm

Cvs:s1s2heard

Rs: BAE+

P/A: soft

A-

Viral pyrexia with acute gastritis

Hb:11gm/dl

Tc:3600

Platelets:1.51

Smear: normocytic normochromic

P-

Inj.Zofer 4mg iv/sos

Inj.PAN 40mg/iv/od

Ivf NS,RL @50ml/hr

Inj.OPTINEURON 1amp in100ml ns/iv/od

Syp.ASCORIL-D 10ml/tid

ORS

Patient was relieved symptomatically and her vomtings was subsided.She had a small daughter , and wanted to take care of her.so, she wanted to go home today(10/10/21). She was discharged at request.

 Diagnosis- viral pyrexia (dengue NS1 positive)

UNIT 5 ADMISSION:

Chief complaints

A 14year old male resident of chanduru came in to casualty with chief complaints of 

fever since 4 days. C/o cough since 4days

Presenting illness

Patient was apparently asymptomatic 4 days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and body pains.

C/O cough since 4 days which is associated with sputum . 

Patient has  h/o  1episode of vomiting 2days back which is non bilious,non projectile.

No h/o pedal oedema,decreased urine output,sob,palpitations.

No h/o chest pain,abdominal pain

PAST HISTORY:

Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.

PERSONAL HISTORY:

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

FAMILY HISTORY

No significant family history or allergic history. 

GENERAL EXAMNATION:

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 100/80 MMHG, 

PR: 90bpm 

Temp: 98.2°F, 

RR: 22 CPM, 

SPO2: 98% 

RS: BAE+,NVBS

Cvs: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities. 

INVESTIGATIONS:

1) HEMOGRAM : 

Hb: 12.6

TLC: 4,200

PCV: 37.6

PLT: 3.41

2) LFT:

TB: 0.76

DB: 0.25

SGOT: 51

SGPT: 21

AP: 519

TP: 6.3

A: 2.2

A/G: 0.55

3)CUE

Alb:trace

Sug:nill

Ec:2-3

Pc:2-3

RBC:bill

4)BLOOD UREA:34

 5)SERUM ELECTROLYTES:

Na+:136

K+:4.1

Cl-:102

Absolute neutrophil count"-

Peripheral smear:-

Rapid dengue test:-

Fever chart

SOAP NOTES DAY 1:-

AMC case

S- complains of fever,cold,cough 

O-bp-130/100

Pr-89

Rr-17

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 75 ml/hr

Tab.augmentin 625 mg po/bd

Tab.dolo 650 mg po/tid

Inj.pan 40 mg/po/od

Inj.optineuron 1 amp in 100 ml NS IV od

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Inj.neomol 1 g/IV/sos only if temperature greater than 101°F

Watch for bleeding manifestations and postural drop.

Soap notes day 2:-

AMC case

14/M

S- no fresh complaints

O-bp-90/60

Pr-88

Rr-17

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 25 ml/hr

Inj.augmentin 1.2g iv/OD

Tab.dolo 650 mg po/tid

Inj.pan 40 mg/po/od

Inj.optineuron 1 amp in 100 ml NS IV od

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Inj.neomol 1 g/IV/sos only if temperature greater than 101°F

Watch for bleeding manifestations and postural drop.

Soap notes day 3:-

AMC case

14/M

S- 1fever spike ,no fresh complaints

O-bp-100/70mmhg

Pr-80

Rr-20

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 100ml/hr

Inj.augmentin 1.2g iv/BD

Inj PCM 1gm IV/sos

Inj.Zofer 4 mg/IV/sos

Tab. Doxycycline 100mg/po/bd

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Watch for bleeding manifestations and postural drop.

Strict temp monitoring 4th hrly

PROVISIONAL DIAGNOSIS:DENGUE FEVER NS1positive

DIABETIC KETOACIDOSIS WITH DENOVO DETECTED DM WITH VIRAL PYREXIA UNDER EVALUATION

HELLO GUYS, 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 evidence based input

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 diagnosis and treatment plan.

UNIT 5 ADMISSION: 

A 21year old male resident of miryalaguda came to the casualty with

Chief complaints:-

Fever since 5 days, decreased appetite since 7days, vomiting  since 1day, sob since morning.

History of presenting illness:-

Patient was apparently asymptomatic 5days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and relieved on medication.  Pt has H/o  1episode of vomiting 1day back which is non bilious,non projectile.

No h/o any burning micturition,throat pain,cold,cough.

PAST HISTORY:-

Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.

PERSONAL HISTORY:-

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:-

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 140/90 MMHG, 

PR: 120bpm 

Temp: 98.2°F, 

RR: 40 CPM, 

SPO2: 99% 

Systemic examination:-

RS: BAE+,NVBS

CVS: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities. 

INVESTIGATIONS:-

1) HEMOGRAM : 

Hb: 8.2

TLC: 15800

N:89

L:6

PCV: 30

Mcv:63.7

MCH:17.4

MCHC:27.3

PLC:3.37

RBC:4.71

2) LFT:

3)CUE

4)RBS:194 

5)BLOOD UREA:29

6)SERUM CREATININE:0.8 

7)URINE FOR KETONE BODIES:

8)ABG@2PM 

9)SERUM ELECTROLYTES @2pm

S.ELECTROLYTES@ 10PM 

10) Chest xray PA view: 

PROVISIONAL DIAGNOSIS:DIABETIC KETOACIDOSIS WITH DENOVO DETECTED DIABETES MELLITUS WITH VIRAL PYREXIA UNDER EVALUATION

TREATMENT: 

On DAY-1

1)NBM till further orders

2)IVF 3lit NS  @500ml/hr(in 3hrs) f/by IVF NS@250ml/hr 

3)Inj. HAI 4IU IV/stat f/b Inj. HAI 1ml (40IU) in 49ml NS @ 4ml/hr(untill ABG correction)

4)Inj. PAN 40mg IV/OD

5)IVF 5%DEXTROSE @50-100ml/hr(when GRBS <150) [increase/decrease acc. to GRBS]

6)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

7)GRBS monitoring hourly

8) Strict i/o. Monitoring

9)Inj. KCl 2amp in 500ml NS @100ml/hr

On DAY-2 :

SOAP NOTES:

S: 

No fever spikes,sob decreased ,no fresh complaints

O:

BP-110/90mm hg

PR-74bpm

CVS:S1S2 heard

Rs:BAE +,NVBS

P/A:soft

A:

HAGMA, DKA

Hemogram:

ABG @1AM

@8AM

@3PM

S.ELECTROLYTES:@8AM

@5PM

@10.30PM

P:

1)IVF 0.45% NaCl,RL @100ml/hr 

2)Inj. KCl 2amp in 500ml NS @100ml/hr

3)Inj. HAI 1ml (40IU) in 39ml NS @ 4ml/hr(untill correction of acidosis)

4)Inj. PAN 40mg IV/OD

5)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

6)GRBS monitoring hourly

7)Strict i/o. Monitoring

8)NBM till further orders

DAY-3 :

S: Patient sob decreased,No fresh complaints

O: BP 110/80 mm hg

PR: 70 bpm

CVS: s1 s2 heard 

RS: BAE+ NVBS 

P/A: soft 

S.ELECTROLYTES @8AM

Assesmemt : over night patient grbs around 290 mg/dl and Patient anion gap is reducing day by day and subjectively feeling better .

Plan : Look for today morning abg and stop iv insulin infusion and start him on NPH and HAI

1601006131 SHORT CASE

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MBBS FINAL SHORT CASE

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35 year old male patient, resident of ramchandrapuram, works as a daily wage labourer, a chronic smoker (1 pack of beedi every 2 days) and a chronic alcoholic (90ml daily) since 20 years presented with a 3 month history of painless papules with erythema that started initially over the face then gradually extended to upper limb, low limbs and trunk 

• No hypodense lesions 
• No fever 
• No pus
• No loss of sensations
• No genital lesions 

Patient got over the counter  topical cream, soap and some oral drugs from nearby medical shop 

He used them for 2 months, few lesions regressed but few persisted on nose, ear lobe, hands, legs and trunk.

14 days ago patient developed blackish skin discolouration over hands and feet with skin peeling, cracking, ulcer formation associated with burning sensation and erythema all over the body.

Since 4 days patient developed continuous high grade fever associated with chills and rigors.

Associated with Loss of appetite 

There is no history of similar complaints in the past 

EXAMINATION:

• Face: loss of eyebrows, thickened earlobe
• Oral cavity: dark erythematous lesions on the palate
• Multiple lesions of different sizes with ill defined erythematous borders and pale hypopigmented centre with peeling and raw areas are seen on trunk, limbs and face
• Scaly hyperpigmented plaques with fissures noted involving the feet Extending  from the sole to the dorsal aspect of the foot

DIAGNOSIS:

Hansen’s disease 

1601006131 LONG CASE

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FINAL EXAM LONG CASE

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A 50 year old female patient a resident of Nalgonda, home maker came to the OPD with chief complaints of pain and stiffness in several joints since 1 year.

History of present illness:

She was apparently asymptomatic 10 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(MCP joints) of right hand with limitations of movements at the joints. 

Then within 6 months of onset the disease progressed to involve other joints of the right hand and left hand as well(wrist joint and elbow joint) 

Within 4 years of onset she started feeling pain in the joints of the feet and ankle joint. 

Since 3 months the pain became unbearable limiting  her activities

The pain was insidious in onset, slowly progressive dull aching type of pain, non radiating, associated with swelling, stiffness and limitations of movements in the involved joints.

Stiffness and pain was more in the first 1 hour of waking up and gradually improved on movement.

There are few exacerbations associated with fever.

• No deformities 
• No loss of weight.
• No involvement of distal interphalangeal joint
• No butterfly rash
• No abnormal jerky movements (chorea)

PAST HISTORY:

She has no similar complaints 10 years ago. 

No history of thyroid, Asthma, hypertension, diabetes 

DRUG HISTORY

No known drug allergies 

MENSTRUAL HISTORY:

• Menarch: 13 years 
• Regular 29 day cycles 
• Menopause: 47 years 

Family history:

No similar complaints

Personal history : 

1. Diet: mixed 
2. Appetite: normal 
3. Bowel and bladder: regular 
4. Sleep: adequate 
5. No addictions 

General examination: 

patient is conscious coherent and cooperative 

Moderately built and nourished 

• No edema
• No icterus 
• No cyanosis 
• No lymphadenopathy 
• No pallor 

VITALS:

1. Temperature: a febrile 
2. Blood pressure: 115/70
3. Respiratory rate: 15 CYCLES/MIN
4. Pulse rate: 76bpm

LOCAL EXAMINATION:

INSPECTION 

Skin : 

No pigmentation 

No scars 

No atrophic changes 

Nails: normal 

Soft tissues: swelling over the joints 

Deformities : no deformities 

PALPATION

Skin: warm

Sensations are preserved 

Soft tissues: no edema 

Joint capsule: mild swelling over the joint 

Tenderness over the joint (squeeze test)

Movements: 

Decreased range of movements at PIP, MCP, wrist, elbow, ankle joints 

All active and passive movements at the involved joints and painful.

EXTRA ARTICULAR MANIFESTATIONS:

Eye: no ocular manifestations (episcleritis, scleritis, keratoconjuctivitis sicca)

Ear: no hearing loss

Muscle: no muscle atrophy 

GIT: no xerostomia, no parotid gland enlargement, no dysphasia 

No lymphadenopathy 

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM

Apex beat: 5th intercostal space lateral to midclavicular line 

S1 and s2 heard 

JVP normal

Pedal edema: absent 

RESPIRATORY SYSTEM

Breath sounds: normal 

No additional breath sounds 

CENTRAL NERVOUS SYSTEM

cranial nerves intact 

Reflexes preserved

Sensations preserved 

Joint position sense: intact 

ABDOMEN

No abnormal findings found

DIFFERENTIAL DIAGNOSIS

1. Osteoarthritis 

2. Rheumatoid arthritis 

INVESTIGATIONS:

1. Complete blood picture 

2. ESR 

3. CRP

4. Rheumatoid factor 

5. Liver function tests 

6. Renal function tests 

7. Urine examination 

8. Antibodies 

9. X-ray 

X ray Findings: 

1. Decreased joint space 

2.osteoporosis 

3. Mild erosions 

Rheumatoid factor: strongly positive 

Anti CCP antibodies: negative

C-Reactive protein: positive 

ESR: Elevated

PROVISIONAL DIAGNOSIS:

                 RHEUMATOID ARTHRITIS 

TREATMENT:

1. Methyl prednisolone 

2. Hydrocortisone 

3. Tramadol hydrochloride