General Medicine - Final practical exam - Long case

June 08,2022

K. Tejasree,1701006075

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.

CASE:

A 46 year old male came to the casualty with complaints of 

Burning micturition since 10days

Vomitings since 2 days

Drowsiness since 1 day

History of present illness

Past History:

No history of previous UTI

He is not a known case of Hypertension, Coronary artery disease, asthma, TB

Personal History:

Appetite- normal

Diet- mixed

Regular bladder and bowel movements

Burning micturition since 10 days(18/05/22)

Addictions: consumes alcohol occasionally but stopped since 1 yr.

General Examination:

Moderately built and nourished.

Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No visible signs of dehydration

Vitals at admission:

BP: 110/80 mm of hg

HR: 98bpm

RR: 18cpm

Temperature: 101 degree farenheit

SpO2: 98% on RA

GRBS: 124 mg/dL

Construction apraxia ( reference picture)

Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: Bilateral air entry is present.

       Normal vesicular breath sounds are heard

P/A

Soft, non tender.

No scars,engorged veins ,sinuses,swelling

No visible gastric peristalsis

No renal angle fullness

CNS: 

Patient is having altered sensorium

Reflexes:

Biceps,Triceps,Supinator,Knee,Ankle,Plantar-All are normal

Power- 5/5 in both upper and lower limbs

Tone- nomal in both upper and lower limbs

Meningeal signs are not seen

Investigations:

On admission 

19.5.22

1) Complete blood picture

2) Complete urine examination

3) Urine for ketone bodies:

4)Renal function tests:

5) Liver function tests:

6) X-ray KUB

20.05.22

1)LDH- 192

2) 24Hr urine creatinine 

3) 24Hr urine proteins

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

23.05.22

1) Bacterial culture and sensitivity report

Culture report: Klebsiella Pneumonia positive

24.05.22

1) 2D Echo:

2) Bacterial culture and sensitivity report

Patient Complained of Sudden diminision of vision in right eye 

Sent for ophthalmologic examination

Diagnosed as secondary angle closure glaucoma 

Treated with timolol bd for 1 week and glycerol 5times daily for 1 week

25.5.22

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

30.05.22

07.06.22

Provisional Diagnosis: 

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

H/o of Type 2 Diabetes Mellitus since 10years

Treatment:

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

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

INJ. COLISTIN 2.25 MU IV OD