202306171

 

 Case History and Clinical Findings

CHIEF COMPLAINTS-

 

GENERALISED WEAKNESS SINCE 1 WEEK COUGH SINCE 4 DAYS

INVOLUNTARY MOVEMENTS OF LT UPPER LIMB SINCE 1 DAY HOPI-

PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN SHE DEVELOPED GENERALISED WEAKNESS

H/O COUGH SINCE 4 DAYS ,PRODUCTIVE, SCANTY SPUTUM -WHITE TO YELLOW IN COLOUR

,NON BLOOD STAINED ,NON FOUL SMELLING

H/O INVOLUNTARY MOVEMENTS OF LT UPPER LIMB SINCE 1 DAY [ TO AND FRO MOVEMENTS]

H/O INADEQUATELY CONTROLLED SUGARS FROM 4 MONTHS H/O FALL ONE WEEK AGO

NO H/O VOMITING ,SOB ,LOOSE STOOLS ,PAIN ABDOMEN,BURNING MICTURITION NO H/O FEVER,COLD,SORE THROAT

NO HISTORY OF SPEECH ABNORMALITIES

NO H/O WEAKNESS IN THE UPPER AND LOWER LIMB NO H/O LOSS OF CONSCIOUSNESS, MEMORY LOSS NO HISTORY OF ABNORMAL POSTURING

H/O FALL FROM BED AND COMPLAINTS OF PAIN IN THE HIP WHICH IS GRADUALLY RESOLVING

K/C/O TYPE 2 DIABETES MELLITUS SINCE 30 YRS ,ON INSULIN 10 YRS (INSULIN LISPRO 20 -X-20 )

K/C/O HTN SINCE 20 YRS ON T PROMOLET XL 50 MG PO/OD AT 10 AM AND T ATENOLOL 25 MG PO/OD

K/C/O HYPOTHYROIDISM SINCE 15 YRS ON THYRONORM 75 MCG

K/C/O RECURRENT URINARY TRACT INFECTION FOR WHICH SHE HOSPITALISED 1 YR BACK NOT A KNOWN CASE OF TUBERCULOSIS,EPILEPSY ,ASTHMA ,CEREBRO VASCULAR ACCIDENT ,CORONARY ARTERY DISEASE .

 

PERSONAL HISTORY:

DIET- MIXED APPETITE- LOST

BLADDER MOVEMENTS WERE REGULAR NON ALCOHOLIC ,CHEWS TOBACCO

 

CHEWS BETEL NUT AND BETEL LEAF TWICE DAILY NO ALLERGIES

 

FAMILY HISTORY-

NO H/O SIMILAR COMPLAINTS IN FAMILY

 

 

O/E OF PATIENT ON ADMISSION-

PT IS CONSCIOUS ,COHERENT, NON COOPERATIVE TEMP : 96.4 F

PR : 76 BPM

BP : 110/70 MM HG RR : 18/MIN

SPO2 98% AT ROOM AIR GRBS : 315 MG /DL PALLOR PRESENT

NO ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY. BILATERAL PITTING TYPE EXTENDING UP TO KNEE

CVS : S1 S2 HEARD NO MURMURS

RS : BILATERAL AIR ENTRY+ NORMAL VESICULAR BREATH SOUNDS+ P/A : SOFT ,NON TENDER

BOWEL SOUNDS HEARD CNS-

MOTOR SYSTEM-

NORMAL TONE IN BOTH UPPER AND LOWER LIMBS POWER 5/5 IN ALL LIMBS

REFLEXES B / T / S / K / A / P

RT 1+ / 1+ / - / 1 + / - / F LT 1+ / 1 + / - / 1 + / - / F

SENSORY EXAMINATION NORMAL NO CEREBELLAR SIGNS

NORMAL GAIT AND NO MENINGEAL SIGNS GCS SCORE E4V5M6

O/E OF PATIENT ON DISCHARGE-

PT IS CONSIUOS ,COHERENT , COOPERATIVE

 

TEMP : 97.4 F PR : 76 BPM

BP : 130/60 MM HG RR : 18/MIN

SPO2 98% AT ROOM AIR GRBS : 191 MG /DL

 

CVS : S1 S2 HEARD, NO MURMURS

RS : BILATERAL AIR ENTRY+,NORMAL VESICULAR BREATH SOUNDS+ P/A : SOFT ,NON TENDER,BOWEL SOUNDS HEARD

CNS-

MOTOR SYSTEM NORMAL TONE IN BOTH UPPER AND LOWER LIMBS POWER 5/5 IN ALL LIMBS

REFLEXES B / T / S / K / A / P

RT 1+ / 1+ / - / 1 + / - / F LT 1+ / 1 + / - / 1 + / - / F

SENSORY EXAMINATION NORMAL NO CEREBELLAR SIGNS

NORMAL GAIT AND NO MENINGEAL SIGNS GCS SCORE- E4V5M6

COURSE IN HOSPITAL-

A 65 YR OLD FEMALE CAME TO THE THE CASUALTY WITH COMPLAINTS OF GENERALISED WEAKNESS SINCE 1 WEEK ,COUGH SINCE 4 DAYS AND INVOLUNTARY MOVEMENTS OF LT UPPER LIMB SINCE 1 DAY

H/O INADEQUATELY CONTROLLED SUGARS FROM 4 MONTHS

PT WAS EVALUATED WITH CLINICAL EXAMINATION AND AFTER NECESSARY INVESTIGATIONS, SHE WAS DIAGNOSED AS HYPERGLYCEMIA WITH CHOREA WITH DIABETIC NEPHROPATHY WITH RECURRENT URINARY TRACT INFECTION WITH IRON DEFICIENCY ANEMIA

AND FOLLOWING TREATMENT WAS GIVEN- NBM TILL FURTHER ORDERS

INJ HAI 6 U /IV/STAT AND FOLLOWED BY INSULIN INFUSION 1 ML/HR IVF NS @ 75 ML/HR

IVF 5D @ 50 ML/HR

 

GRBS AND VITALS MONITORING HOURLY

USG ABDOMEN AND PELVIS SHOWED BILATERAL GRADE 1 -2 RPD CHANGES WITH RAISED ECHOGENICITY

ECG SHOWED NORMAL SINUS RHYTHM

 

 

DAY 2

INVOLUNTARY MOVEMENTS OF LT UPPER LIMB NOT REDUCED

INSULIN INFUSION CHANGED TO SUBCUTANEOUS ROUTE, HAI AND NPH GIVEN ACCORDING TO GRBS

T PROMOLET XL 50 MG PO/OD AT 8 AM ,T THYRONORM 75 MCG PO/OD AT 7 AM ,T TETRABENAZINE 12.5 MG PO/OD AT 8 AM ADDED TO THE TREATMENT

T ATENOLOL WAS WITH HELD

OPHTHALMOLOGY OPINION WAS TAKEN IN VIEW OF ANY DIABETIC AND HYPERTENSIVE RETINOPATHY CHANGES

ON FUNDUS EXAMINATION NO CHANGES WERE NOTED IN RETINA . 2D ECHO WAS DONE SHOWED-

NO RWMA ,CONCENTRIC LVH + MILD MR+/AR+;TRIVIAL TR+ SCLEROTIC AV ,NOAS/MS

EF 58% ,RVSP=35 MMHG GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION +,NO PE IVC SIZE (1.O7CMS) COLLAPSING

 

DAY 3

INVOLUNTARY MOVEMENTS WERE REDUCED COMPARED TO PREVIOUS DAY INJ NPH WAS WITH HELD

DERNATOLOGY OPINION WAS TAKEN IN VIEW OF DRY,BROWN SCALY LESIONS ON BOTH BOTH LEGS EXTENDING TILL KNEES

AND WAS DIAGNOSED AS SNILE XEROSIS AND ADVICED LIQUID PARAFFIN L/A BD FOR 4 WEEKS T TECZINE 5 MG SOS

BLOOD SENT FOR CULTURE SENSITIVITY SHOWED NO GROWTH NEUROLOGY OPINION WAS TAKEN AND ADVISED FOR MRI BRAIN

 

ANESTHESIOLOGIST OPINION WAS TAKEN FOR SEDATION FOR MRI

SO PAC WAS DONE I/V/O MRI UNDER SEDATION .PATIENT ATTEDERS WERE EXPLAINED ABOUT THE PROCEDURE AND POSSIBLE RISKS ASSOCIATED WITH MRI SEDATION

BUT PATIENT ATTENDERS REFUSED TO GIVE CONSENT AND MRI BRAIN WAS NOT DONE

 

 

DAY 4

INVOLUNTARY MOVEMENTS WERE REDUCED COMPARED TO PREVIOUS DAY

CULTURE AND SENSITIVITY OF URINE SAMPLE SHOWS ESCHERICHIA COLI >100000 CFU/ML OF URINE ISOLATED AND 5-6 PUS CELLS SEEN /HPF .

SENSITIVITY SEEN TO GENTAMICIN,FOSFOMYCIN,AND AMIKACIN INTERMIDIATE SENSITIVITY SEEN TO NITROFURANTOIN RESISTANT TO

AMOXYCLAV,CEFUROXIME,NORFLOX,COTRIMOXAZOLE,OFLAXACIN,CEFTAZIDINE,CEFEPIM

E,PIPERACILLIN/TAZOBACTAM.

 

 

DAY 5

SLIGHT INVOLUNTARY MOVEMENTS WERE NOTED INSULIN DOSE WAS FIXED ,HAI 8U----8U-------------------------------------------------- 8U

 

DAY 6

REDUCED INVOLUNTARY MOVEMENTS COMPARED TO PREVIOUS DAY

 

 

DAY 7

PATIENT IS SHIFTED TO ICU AT 12 AM IN VIEW OF FALLING SATURATIONS 60% AT ROOM AIR AND FEVER 100.7F

COMPLAINTS OF SHORTNESS OF BREATH

SHE WAS PUT ON INJ AUGEMENTIN 1.2 G IV BD

NEBULIZATION WITH BUDECORT AND MUCOMIST 8TH HOURLY INTERMITTENT CPAP

TAB NICARDIA 10MG PO/OD STAT GIVEN

PATIENT CONDITION HAS BEEN EXPLAINED TO THE ATTENDERS IN THEIR OWN UNDERSTANDABLE LANGUAGE ABOUT THE RISK ASSOCIATED WITH THE CONDITION AND IN NEW FALLING SATURATION AND POSSIBLE NEED FOR EMERGENCY INTUBATION

 

CHEST XRAY WAS DONE WHICH SHOWED LEFT SIDED OPACIFICATION[?CARDIOGENIC PULMONARY EDEMA ?PNEUMONIA]

 

DAY 8

INVOLUNTARY MOVEMENTS REDUCED COMPARED TO THE PREVIOUS DAY PATIENT COMPLAINS OF COUGH WITH EXPECTORATION

SPUTUM FOR AFB,GRAM STAIN AND ULTURE AND SENSITIVITY SEND

PULMO OPINION WAS TAKEN I/V/O HOSPITAL ACQUIRED PNEUMONIA AND ON EXAMINATION BILATERAL AIR ENTRY PRESENT

CREPS PRESENT AT INFRASCAPULAR REGION LEFT .RIGHT AND INTERSCAPULAR REGION AND LEFT IAA

THEY ADVISED CST,SYRUP ASCORIL LS 2TSP PO TID,NEBULIZATION WITH MUCOMIST BD,AND PLAN FOR BRONCHOSCOPY ONCE THE PATIENT IS STABLE

2D ECHO WAS DONE

RWMA PRESENT,LAD HYPOKINESIA,MILD LVH PRESENT [1.28CM]

MILD MR PRESENT,MODERATE TO SEVERE TR PRESENT WITH PAH,MODERATE AR PRESENT

SCLEROTIC AV NO AS/MS

EF 52% FAIR TO MILD LV DYSFUNCTION DIASTOLIC DYSFUNCTION PRESENT NO PE

IVC SIZE [1.64CM]DILATED COLLAPSING MILD DILATED RA/LA

 

DAY 9

NO FEVER SPIKES SINCE PREVIOUS DAY INVOLUNTARY MOVEMENTS ABSENT TAB TETRABENAZINE STOPPED

COUGH WITH EXPECTORATION REDUCED COMPARED TO THE PREVIOUS DAY INJ HAI S/C GIVEN TID 8 UNITS AT AM-1PM-8PM

SPUTUM FOR CULTURE SENSITIVITY -PSEUDOMONAS SPECIES IS ISOLATED SENSITIVE TO

PIPERACILLIN,GENTAMICIN,CIPROFLOXACIN,CEFTAZIDIME,AMIKACIN,CEFEPIME,TAZOBACT

EM,MEROPENEM

 

DAY 10

NO FEVER SPIKES SINCE PREVIOUS DAY INVOLUNTARY MOVEMENTS ABSENT

COUGH WITH EXPECTORATION REDUCED COMPARED TO THE PREVIOUS DAY

 

 

DAY 11

NO COMPLAINTS AND PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE STATE

 

 

Investigation

2D ECHO WAS DONE SHOWED NO RWMA ,CONCENTRIC LVH + MILD MR+/AR+;TRIVIAL TR+ SCLEROTIC AV ,NOAS/MS

EF 58% ,RVSP=35 MMHG GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION +,NO PE IVC SIZE (1.O7CMS) COLLAPSING

 

USG ABDOMEN WAS DONE SHOWED

BILATERAL GRADE 1 -2 RPD CHANGES WITH RAISED ECHOGENICITY

 

 

ECG SHOWS NORMAL SINUS RHYTHM

 

 

HBA1C 7%

HAEMOGRAM OF PT SHOWS HAEMOGRAM HB / TLC / RBC / PLT 7/2/23 7.9 / 13,100 / 4.34 / 2.50

8/2/23 8.4 / 11,000 / 4.55 / 2.99

11/2/23 8.0 / 13,700 / 4.31 / 2.74

SERUM OSMOLALITY 277.9

SPOT URINE PROTEIN 90.5

SPOT URINE CREAT 25.7SPOT URINE PROTEIN/CREATININE RATIO 3.52

 

 

 

CULTURE AND SENSITIVITY OF URINE SAMPLE SHOWS ESCHERICHIA COLI >100000 CFU/ML OF URINE ISOLATED

AND 5-6 PUS CELLS SEEN /HPF .

SENSITIVITY SEEN TO GENTAMICIN,FOSFOMYCIN,AND AMIKACIN INTERMIDIATE SENSITIVITY SEEN TO NITROFURANTOIN RESISTANT TO

AMOXYCLAV,CEFUROXIME,NORFLOX,COTRIMOXAZOLE,OFLAXACIN,CEFTAZIDINE,CEFEPIM

E,PIPERACILLIN/TAZOBACTAM.

 

 

URINE FOR KETONE BODIES WERE NEGATIVE

 

 

BLOOD SENT FOR CULTURE SENSITIVITY SHOWED NO GROWTH

 

 

SPUTUM FOR CULTURE SENSITIVITY -PSEUDOMONAS SPECIES IS ISOLATED

 

 

Treatment Given(Enter only Generic Name)

INJ HAI SUBCUTANEOUS 8U---8U---8U [8AM--1PM --8PM] IVF NS @ 75 ML/HR

INJ AUGMENTIN 1.2G IV/TID

T PROMOLET XL 50 MG PO/TWICE DAILY AT 8 AM----- 8PM

T THYRONORM 75 MCG PO/ONCE DAILY AT 8 AM

T TETRABENAZINE 12.5 MG PO/THRICE DAILY AT 8 AM -2PM-8PM LIQUID PARAFFIN L/A TWICE DAILY 8AM---------------------------------------------- 8PM

T TECZINE 5 MG SOS

INJ LASIX 20MG IV/TWICE DAILY 8AM----- 4PM

SYRUP ASCORIL LS 10 ML PER ORAL THRICE DAILY GRBS 7.O PROFILE MONITORING

STRICT I/O CHARTING MONITOR VITALS

Advice at Discharge

INJ HAI SUBCUTANEOUS 6U----6U---- 6U[8AM-1PM-8PM]

TAB ECOSPIRIN -AV 75/20 PO ONCE DAILY AT 8PM

TAB HYDRALAZINE 12.5MG PO ONCE DAILY FOR 1 WEEK AT 8 AM

 

TAB LASIX 20MG PO/BD FOR ONE WEEK 8 AM--------- 4PM

T PROMET-XL 25 MG PER ORAL TWICE DAILY AT 8 AM---- 8PM

T THYRONORM 75 MCG PER ORAL ONCE DAILY AT 8 AM

LIQUID PARAFFIN LOCAL APPLICATION TWICE DAILY [MORNING AND NIGHT] FOR 4 WEEKS SYRUP ASCORIL LS 10ML PO TID 8AM-----2PM------------------------------------------------------------------------- 8PM

T TECZINE 5 MG PER ORAL SOS STRICT DIABETIC DIET


Comments

Post a Comment

Popular posts from this blog

202311494

    Case History and Clinical Findings DEATH SUMMARY 50 YEAR OLD MALE CAME WITH CHIEF COMPLAINTS OF SOB SINCE 10 DAYS AND EDEMA OF UPPER LIMB AND LOWER LIMB SINCE 6 DAYS. HE WAS MANAGED BY GIVING INJ LASIX 40 MG AND RATE CONTROLLING T. MET XL 25 MG GIVEN. HE WAS SHIFTED TO AMC. IN VIEW OF GLOBAL HYPOKINESIA HE WAS STARTED ON ANTI PLATELET. IN VIEW OF HIGH CREATININE LEVELS NEPHRO OPINION WAS TAKEN AND THEY SUGGESTED CONSERVATIVE MANAGEMENT   ON 16/03/2023 PATIENT SUDDENLY DEVELOPED SINUS TACHYCARDIA AND SHIFTED TO ICU AND GIVEN RATE CONTROLLING AGENTS WERE GIVEN. SINCE YESTERDAY MORNING HE IS COMPLAINING OF GIDDINESS AND CEREBELLAR SIGNS WERE NEGATIVE AND RULED OUT CENTRAL CAUSE. IN VIEW OF INCREASED CREATININE PATIENT IS ADVISED FOR DIALYSIS BUT PATIENT ATTENDERS WERE NOT WILLING FOR DIALYSIS. YESTERDAY NIGHT [18/03/2023] PATIENT WAS DROWSY BUT AROUSABLE. TO RULE OUT ANY INFAR...
Read more
Image
27 year old male with pain abdomen  July 20, 2022   THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT  27 year old male painter by occupation was brought to causality with chief complaints of pain abdomen . HOPI  Patient was apparently alright 40 days back then he developed pain and burning sensation in the abdomen which is squeezing type and diffuse all over the abdomen relieved after passing stools . Stool - frequency: 3 times a day , Small amounts , non blood , normal in consistency, mucoid ,non foul smelling , non floating and yellow in color  Not associated with fever , vomitings ,headache, burning micturation, SOB , cold&cough, chills a...
Read more

202308047

  Case History and Clinical Findings C/O ABDOMINAL DISTENSION SINCE 1WEEK C/O DECREASED APETTITE SINCE 1 WEEK C/O DECREASED URINE OUTPUT SINCE AFTERNOON PT WAS APPARENTLY ALRIGHT 1MONTH BACK THEN HE DEVELOPED PAIN ABDOMEN ON AND OFF , THEN HE DEVELOPED ABDOMINAL DISTENSION , WHICH WAS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE IN NATURE .   NO H/O FEVER , NAUSEA , VOMITING ,LOOSE STOOLOS , CONSTIPATION HE HAD LOSS OF APPETITE SINCE 1 WEEK AND DECREASE IN URINE OUTPUT SINCE AFTERNOON. NOT A K/C/O DM ,HTN , ASTHMA , TB , CAD , CVA , EPILEPSY OCCASIONAL ALCOHOL INTAKE , NO H/O SMOKING . GENERAL EXAMINATION : PT IS C/C/C, MODERATELY BUILT AND NOURISHED NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING , LYMHADENOPATHY , EDEMA AFEBRILE PR -120BPM BP - 130/80 MMHG RR - 20CPM SPO2 - 98% AT ROOM AIR GRBS - 108MG% CVS - S1S2 HEARD , NO MURMURS CNS-HMF INTACT . NFND RS -BAE PRESENT , NO ADDED SOUNDS P/A - ABDOMEN DISTENDED , UMBILICUS ...
Read more