General Medicine ELog
M.ANURAG, MBBS 9TH SEMESTER
Roll no:72
This is 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 patients 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 comment box is welcome
I have 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 a treatment plan.
(Contains information collated from Dr.Manasa PG, Dr.Harika Intern and from the patient)
CASE DISCUSSION:
42 yr old male patient , electrician, came to casualty with cheif complaints of
•Shortness of breath grade 4 progressed since 4-5days
•abdominal distension since 4-5 days
•Swelling of both the legs upto ankle since 4-5 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic until July 21 when he was presented to Kims narketpally, with symptoms of Shortness of breath, pedal edema, and was diagnosed with Heart failure , COPD which was managed witth diuretics and beta blockers.
The patient also had a ulcer on his left foot which was treated by transplanting a skin graft from his left thigh.
Patient continued to consume alcohol 15days after discharge with increased binge drinking since 10days.
Then the patient developed cough, which was productive, had no diurnal variation ,was associated with low grade fever and shortness of breath ,which progressed to grade 4 gradually, was associated with orthopnea, abdominal distension and bilateral pedal edema upto ankle due to which the patient presented again to kims Narketpally.
PAST HISTORY:
The patient had his left foot big toe get hit by iron rod during work, for which he used pain killers but it did not subside, foot got swollen the next day, due to which he came to our hospital. Then the skin flap from right thigh is grafted to his left foot. He then used regular medication for given period. He was fine till 2yrs, then got diagnosed for TB , used medication only for 4days .
Now before 3months , he got admitted due to jaundice in our hospital, after admission,next day he developed ulcers on left foot ankle, treatment was being given, now again multiple ulcers were developed.
The patient was diagnosed with Tuberculosis 1yr for which he used medication for 4days and stopped.
Not a known case of diabetes/ hypertension/ asthma/epilepsy.
PERSONAL HISTORY:
Diet : mixed
Appetite: normal
Sleep: adequate
Bowel and bladder habits: regular
Addictions: The patient is a chronic alcoholic He consumes 180ml whiskey/day since 20yrs .
He consumes gutka consumption since 20yrs.
No similar complaints in the past.
Before 2018 , he was fine with his routine work life.
GENERAL EXAMINATION :
Patient is conscious, coherent,co operative and well oriented to time place and person
No signs of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy.
VITALS:
Temperature : Afebrile
Blood Pressure: 90/60mmhg
Pulse Rate : 112bpm
respiratory rate: 34CPM
Spo2: 89% room air
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
Parasternal heave present
Apex - visible, diffuse.
S1 and S2 heard, No murmurs present.
RESPIRATORY SYSTEM:
Dyspnea: grade 4
Wheeze present , bilateral end inspiration present
Position of trachea: central
Adventitious sounds :
Rhonchi present , rales present , in bilateral ISA
PER ABDOMEN:
Soft,Distended.
No tenderness.
Shifting dullness present
Bowel sounds heard.
CENTRAL NERVOUS SYSTEM :
Cranial nerves: Intact
Sensory system: sensitive to touch and pain
Motor system:
Right Left
Power: UL. Normal Normal
LL Normal. Normal
Tone: UL Normal Normal
LL. Normal Normal
Reflexes: Ellicted
Gait: Normal
Cerebellar system: Intact
INVESTIGATIONS:
Serum creatinine: 2.1
Blood urea : 75
Serology: negative
2D ECHO:
Moderate to severe TR+ with PAH : mild MR+ , trivial AR +
Global akinetic , no AS/MS
severe LV dysfunction.
No diastolic dysfunction,
No LV clot.
BLOOD UREA: 75mg/dl
Plueral fluid analysis
Volume -3ml
Appearance- clear
Colour- pale yellow
Total count- 10cells
DC= 100% L
RBC - nil
Others- nil
PROVISIONAL DIAGNOSIS:
•Heart failure with reduced ejection fraction of EF=27%.
•Beri Beri due to vitamin B deficiency.
•h/o paroxysmal AF (resolved)
•Right sided pleural effusion, secondary to
Consolidation
•Heart failure
•AKI cardiorenal type 2
•Left non healing ulcer over foot
TREATMENT:
1. 02 Inhalation @ 4Litres/min.
2.propped up posture.
3.fluid restriction < 1liter/day
4. Salt restriction < 2gm/day
5.Inj. Lasix 40mg / i.v / TID
If SBP > 100mmhg.
6.Tab. Ecospirin-Av 75/20mg OD
7. Inj. Thiamine 3amp /i.v / in 100ml NS stat
8. Neb with IPRAVENT , DUOLIN /stat
IPRAVENT= 8th hourly
BUDECORT = 12th hourly.
9. Strict I/o monitoring.
10. BIPAP intermittently every 2hrs.
11.Foleys catheterization
12.Inj. Lasix 10amp (vials)
20ml.lasix + 30ml NS= 200mg.
1ml= 200/50= 4mg.
At 2ml/hr ( 8mg/hr).
13. T. Met Xl 25mg /po/stat
14. Inj. HYDROCORTISONE 100mg/i.v /stat
15. PLEURAL TAP DONE .
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