174 P.Tharun

General medicine  E - LOG Book 

Final practical examination : long case 

P.Tharun

Hall ticket number : 1701006135


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

A 46 yr old male came with 
c/o drowsiness (altered sensorium) since 19/5/2022 morning,
c/o vomiting (3-4 episodes) since 2 days
Burning micturition  since 10 days

History of presenting illness : 

Pt was apparently asymptomatic 
5 days back, then pt developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.

Pt c/o deviation of mouth to right side  and giddiness since yesterday night(18/05/2022)
Yesterday night(18/5/2022)- GRBS recorded high value for which he was given NPH 10 IU and HAI 10 IU

No c/o fever/cough/cold
No significant h/o previous UTIs
No c/o chest pains/palpitations/syncopal attacks

Past History:

10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on OHA 10 yr back, 

h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation 1yr back i/v/o development of wet gangrene

OHAs been converted to Insulin since 2 yrs
Delayed Wound healing present- wound healing took 2 months time to heal
3 years back pt underwent Cataract surgery

K/c/o DM type 2 on medication-insulin

Not a k/c/o HTN/Epilepsy/TB/Thyroid disorder/CAD/CVD
Not on any other medication
No h/o blood transfusion

Personal History : 

Appetite-Normal
Diet-Vegetarian
Bowel and Bladder - Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol- 
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
Also 1 month on & off consumption pattern previously present

Family history:

Not significant

Vitals @ Admission:

BP: 110/80 mmHg
HR: 98 bpm
RR: 16cpm
TEMP: 101°f

General Examination:

Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal


Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs


Clinical Images:


 





Investigations:

On admission (19.5.22)

X-ray kUB

20/5/22

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

Culture report: Klebsiella Pneumonia positive

21/5/22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.2/22

25/2/22

27.5.22

Hb- 7

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

Provisional Diagnosis: 

Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years

Treatment:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000




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174 P.Tharun

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General medicine  E - LOG Book      Final practical exam:short case  P.tharun  Hall ticket number:1701006135   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 CASE PRESENTATION : A 22years old male patient came to opd with chief complaint of following Pain abdomen since 4 days ago  History of present illness : Patient was apparently assymptomatic 4 months back ; then he developed vomiting and pain abdomen presented in hospital and diagnosed as acute pancreatitis;he was treated and On discharge he was advised to stop drinking alcohol Then 4 days later he developed pain over abdomen which is of dragging type,radiating to back,aggravated pain when lyi
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