A CASE OF 55 YEAR OLD

 Name: K.Sannith Reddy

Roll no. 65

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 a diagnosis and treatment plan.

Following is the view of my case :

Cheif complaints: 

55 year old male cattle rearer by occupation was brought to the casualty with complaints of Inability to move left sided upper and lower limb since 6 days

Inability to speak since morning

History of presenting illness: 

Patient was apparently asymptomatic 6 days back then he developed weakness of left upper and lowerlimb after waking up from sleep

For which he was taken to hospital and diagnosed to have multiple infarcts in frontotemporal  areas was treated conservatively

During the stay patient developed an episode of seizure

Lasted for 10 min ?focal seizure   , post ictal confusion for 15min 

Later patient was discharged 

Yesterday night patient had an episode of seizure , focal tonic clonic involving left upperlimb for 5minutes , gained consciousness after 10 minutes 

Following which  patient was unable to speak patient is conscious and devoloped weakness in left upper limb and lower limb also devoloped  urinary incontinence not a/w vomitings

Pasthistory: 

- K/C/O Dm since 5 years (under irregular medication)

K/c/o HTN 

N/k/c/o asthma ,CAD , TB

Had left index finger amputated 

PERSONAL H/O:

APPETITE NORMAL

DIET MIXED

SLEEP: ADEQUATE 

BOWEL MOVEMENTS REGULAR AND BLADDER: URINARY INCONTINENCE PRESENT 

NO KNOWN ALLERGIES

FAMILY HISTORY: NO RELEVANT FAMILY HISTORY.

GENERAL EXAMINATION: 

PT is c/c/c 

No palor icterus cyanosis clubbing lymphadenopathy,edema 

Vitals @admission: 

Temp afebrile

Pr 88bpm

Bp 110/70

Spo2 98%

SYSTEMIC EXAMINATION: 

cvs :JVP not raised, s1 s2 heard 

RS: BAE + NVBS heard 

p/A soft non tender 

CNS : 

HMF present ,oriented to time ,place and person 

Tone : RT LT

UL     N. Hyper

LL      N. Hyper 

POWER 

UL      5/5. 2/5

LL       5/5 2/5 

REFLEXES: B. T. S. K. A. Plantar

RT.            ++. ++. +. ++. + extension  

LT.            ++. ++. +. ++. +. extension

INVESTIGATION: 

PROVISIONAL DIAGNOSIS: 

1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)

2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE 

3)WITH TYPE 2 DM SINCE 5YEARS 

Treatment: 

On 24/12/22 

INJ HAI s/c ACC TO GRBS

INJ MANNITOL 300 ML iv TID 

INJ LEVIPILL500 MG IV BD 

TAB ATORVAS 10 MG PO/HS 

On 25/12/22 AMC DAY2 

S

no fever spikes 

stools not passed 

O 

pt is c/c/c 

temp : afebrile

pr 68bpm 

bp: 110/70mm hg 

spo2 98% on ra 

grbs: 163 mg/dl

GRBS AT 

10pm- 160

12am-185

2am-152

4am-149

6am-168

8am-163(12 units HAI given)

cvs :JVP not raised, s1 s2 heard 

RS: BAE + NVBS heard 

p/A soft non tender 

CNS : 

HMF present ,oriented to time ,place and person 

Tone : RT LT

UL     N. Hyper

LL      N. Hyper 

POWER 

UL      5/5. 3/5

LL       5/5 4/5 

REFLEXES: B. T. S. K. A. Plantar

RT.           ++. ++. +. ++. + extension   

LT           ++. ++. +. ++. +. extension

A 

1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)

2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE 

3)WITH TYPE 2 DM SINCE 5YEARS 

 

RX 

 INJ HAI s/c ACC TO GRBS

INJ MANNITOL 300 ML iv TID 

INJ LEVIPILL500 MG IV BD 

TAB ATORVAS 10 MG PO/HS

A CASE OF 60 YEAR OLD

 Name: K. Sannith Reddy

Roll no. 65

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 a diagnosis and treatment plan.

Following is the view of my case :

Cheif complaints

A 60 year old male was brought to casualty with altered sensorium since yesterday night

History of presenting illness: 

Patient was apparently asymptomatic 10 years back then he developed similar kind of symptom and was diagnosed with type 2 DM and started on OHA's later after few years (?3y) patient was shifted to Insulin (HAI twice daily)

After 4yrs Patient developed giddiness and while working patients had fall ,fracture Rt UL and Rt LL And diagnosed with HTN-( on anti hypertensive medication- Telma50 -ch12.5,METXL 40 )

2 yrs back patient developed similar episodes of altered sensorium and was having Hyperglycemia he went to pvt hospital at pvt hospital then was diagnosed to have? DKA → given Insulin and treated.

10 days back pt developed swelling of lower limb , and ulceration on right toe and Plantar aspect of foot for which he went to put practictiner and diagnosed to have diabetic foot and was treated with regular dressings and antibiotics.

From 4 days pt had nausea and vomitings (2 episodes per day) with food intake ,non blood tinged 

vomitings not associated with fever ,cold ,cough,Pain abdomen, loose stools 

Past history: 

N/K/C/O asthma, CAD, Epilepsy 

PERSONAL HISTORY 

DIET MIXED 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS REGULAR 

ALCOHOL OCCASIONAL 

NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION : 

PT IS drowsy 

NO PALOR, ICTERUS ,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY 

Vitals @ admission 

Temp 98.6 F 

Pr 86bpm

Bp 130/80mm hg 

Spo2 97%

GRBS 123mg/dl

SYSTEMIC EXAMINATION: 

CVS - S1,S2 +

RS - BAE + , NVBS

CNS - Pt is drowsy , arousable to deep pains

speech slurred 

No meningial signs 

GCS E3 V2 M5

Tone : RT   LT

UL.    N         N

LT.       N.      N

REFLEXES: B. T.   S. K.  A.  Plantar

RT.              ++. ++. +. ++. +  flexion 

LT.                +. +  . +.   +   + flexion 

INVESTIGATION:

CHEST XRAY :

         

USG ABDOMEN
       

MRI BRAIN: 

PROVISIONAL DIAGNOSIS: 

)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

TREATMENT: 

Given on 24/12/22

Iv fluids 3% Nacl @ 15ml/hr

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

Inj.kcl 20 Meq in 100 ml NS over 2 hrs /IV / STAT

Inj Zofer 4 mg /Iv/Tid

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

Syp. potchlor 15ml/po/Tid

INVESTIGATION CHART

ICU DAY2 25/12/22

 

AGE : 60Y GENDER :M

S: 

No fever spikes

cough with sputum

O:

Pt is drowsy but arousable 

oriented to person but not time and place 

BP - 140/80 mm Hg

PR - 83 bpm

RR 21cpm

SPO2 - 98% @ RA

GRBS - 116 mg/dl

Temp - 98.4 F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

CNS - Pt is conscious but drowsy 

No meningial signs 

GCS E3 V4 M6

Tone : RT LT

UL N. N

LL N. N

REFLEXES: B. T. S. K. A. Plantar

RT. +. + . +. +. + flexion 

LT. +. +. + + + flexion 

A: 

1)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

P: 

Iv fluids 3% Nacl @ 15ml/hr( increase or decrease

 acc to serum electrolytes

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

(D1)Inj monocef 1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

(W/H)tab aldactone. 25 mg po bd 

tab nicardia @10 mg po bd 

coconut water through ryles tube 50ml bd 

Syp. potchlor 15ml/po/Tid

A CASE OF 65 YEAR OLD FEMALE

 Name: K.Sannith Reddy

Roll no. 65

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 a diagnosis and treatment plan.

Cheif complaints: 

patient came to the General medicine Opd with clo Cough (dry) & SOB 2months ago 

HISTORY OF PRESENT ILLNESS

Patient was  apparently asymptomatic till 2months ago. Then she had Dry Cough with SOB for 2 days she went to RMP doctor and she was treated with medication ( unknown) then symptoms subsided 

she is farmer by occupation 2 months age while she is carrying Dry grass she had sudden onset of cough and sob started in the evening and present for two days; went to Rmp doctor and managed with medications (unknown) .

 

Cough is dry; Intermmitent not associated

with chest pain while coughing.

 Not associated with Fever,Headache. 

SOB (G-II) on lifting weights. Relieves after taking medications( unknown) 

not alw orthopnea, & PND, Palpitations,chest pain 

 HISTORY OF PAST ILLNESS

N/Klc/o HTN/DM/CAD/ Epilepsy/ TB /CVA

PERSONAL HISTORY 

DIET MIXED 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS REGULAR 

ALCOHOL OCCASIONAL 

NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION : 

PT IS C/C/C WELL ORIENTED TO TIME ,PLACE AND PERSON 

vitals @ admission : 

BP: 150/90mm hg 

PR: 80BPM,REGULAR 

GRBS: 447MG/DL 

TEMP AFEBRILE  

NO PALOR,ICTERUS,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY 

SYSTEMIC EXAMINATION: 

RS: BAE+ , NVBS HEARD ,

CREPTS ABSENT, NO WHEEZE,NO RHONCHI 

CVS S1,S2 HEARD ,NO MURMURS 

P/A SOFT ,NT 

CNS: NFND

INVESTIGATIONS: 

GRBS 

At the time of admission : 447mg/dl

22/12/22

8 am 122mg/dl 

10am 104mg/dl (6units HAI +6unitsNPH given)

10pm 205mg/dl

23/12/22

2am -160mg/dl

8 am 134mg/dl

Hemogram: 

HB: 12:4

PCV: 36.1

TC: 7200

NEU: 54

MCV: 86.6

MCH: 29.7

LYM: 36

MCHC-34.3

MON: 07

RDW-CV. 11.4

EOS: 03

RBC: 4.17

PLT 2.38 lakh

CUE : 

ALBUMIN TRACE 

SUGARS NIL

PUS CELLS 2-3 

Urine for ketones neagtive 

Fbs- 100mg/dl

Plbs- 152mg/dl

HbA1c 6.8

Chest xray: 

Showing mediastinal lymphnode 

ECG: 

Showing Normal sinus rythm .

2d echo: 

mitral valve : pml calcification, restricted.

RVSP:35MM HG , Ef 67%,IVC 0.9cm

+ Mild AR+/MR+,Trivial TR+ 

NO RWMA ,no AS/MS ,sclerotic Av

Good LV systolic function

Diastolic dysfunction+ NO PAH/PE

Provisional diagnosis: 

1)? Acute exacerbation of asthma 

2)? Allergic bronchitis

Treatment given : on 22/12/22

1) TAB MONTEK LC PO BD (1-X-1)

2) SYP GRYLLINCTUS 15ML PO BD

 3) TAB DOLO 650 MG PO SOS

4)6units HAI + 6 UNITS NPH 

Treatment given on 23/12/22

1) TAB MONTEK LC PO BD (1-X-1)

2) SYP GRYLLINCTUS 15ML PO sos

3) TAB DOLO 650 MG PO SOS

4) TAB GLIMI M1 PO OD at 8am BBF

A CASE OF 44 YR OLD MALE

 Name: K.sannith reddy 

Roll no. 65

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 a diagnosis and treatment plan.

Following is the view of my case :

44 yr old male pt came to the casualty with 

c/o loss of appetite since 1 month 

cough with expectoration since 10days 

sob (grade4) since 4 days 

pt was apparently asymptomatic 10 years back then he developed loss of appetite ,yellow discoloration of sclera ,he went to local hospital and was told he had jaundice releived on taking herbal medication for 10 days 

then he was fine till one month back then hep developed loss of appetite since then he had decreased intake of food then he developed cough with expectoration sputum os scanty whitish in colour cough increases at night then he devoloped Sob(grade 4) since 4days 

no h/o fever ,cold, body Pains,headache,nausea,vomiting ,chestpain , Palpitations,orthopnea,pnd

PAST HISTORY

N/K/C/O HTN,DM,ASTHMA,TB, EPILEPSY,CAD

PERSONAL H/O:

APPETITE DECREASED 

DIET MIXED

SLEEP: ADEQUATE

BOWEL AND BLADDER: REGULAR

NO KNOWN ALLERGIES 

FAMILY HISTORY: NOT SIGNIFICANT 

GENERAL EXAMINATION: 

PT IS C/C/C 

WELL ORIENTED TO TIME ,PLACE AND PERSON 

NO PALOR, ICTERUS ,CYANOSIS, LYMPHADENOPATHY, EDEMA

VITALS AT ADMISSION:

BP: 100/60MMHG

PR: 120BPM

RR: 18CPM

SPO2: 90%AT RA

SYSTEMIC EXAMINATION: 

CVS - S1 S2 + NOMURMURS,JVP NOT RAISED 

RS - BAE + , CREPTS + IN LEFT IAA AND LT.ISA

REMAINING AREAS NVBS HEARD 

OTHER AREAS- NVBS HEARD

P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS + 

CNS -

RHOMBERG POSITIVE

GAIT NORMAL 

MOTOR        UL LL

POWER. RT 5/5. 5/5

                LT 5/5. 5/5

TONE. RT N N

            LT N N

INVESTIGATIONS: 

USG ABDOMEN : IMPRESSION- GRADE 1 FATTY LIVER 

CHEST X RAY : 

ECG : 

2D ECHO : 

NO RWMA ,MILD LVH + 

MILD AR+ ,TRIVIAL TR+,NO MR 

SCLEROTIC AV ,NO AS/MS 

EF 60% RVSP 35MM HG 

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION +,NO PE/PAH 

IVC SIZE 1.15CM 

DIAGNOSIS:

)? ALCOHOLIC LIVER DISEASE 

2)RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB

3) BICYTOPENIA WITH ANEMIA UNDER EVALUATION. ? B12 DEFECIENCY SECONDARY TO ALCOHOL

4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)

TREATMENT GIVEN : 

17/12/22

AGE 44

SEX MALE

S

- EPISODE OF SEIZURE ACTIVITY at 1:30 AM

- PASSED STOOLS 2 TIMES

O

PT IS C/C/C

BP- 100/60mm HG

PR -122/min

SPO2 - 93

TEMP - 100 F

CVS - S1 S2 + NOMURMURS

RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA

P/A - SOFT NT

CNS - NFND

A

? CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL 

RT.MIDDLE LOBE CONSOLIDATION..? CAP.? TB

 WITH ANEMIA UNDER EVALUATION.

P 

O2 INHALATION if O2 sat <90% 

INJ AUGMENTIN 1.2g IV BD 

INJ PAN 40 MG PO OD 

INJ THIAMINE 200mg IN 100ML NS IV BD 

OVER 30MIN 

INJ OPTINEURON 1 AMP IN 100ML NS IV OD OVER 30MIN 

TAB HEPAMERZ 500mg PO BD 

TAB UDILIV 300mg PO BD 

TAB PCM650 MG PO SOS 

SYP APTIVATE 15ml PO BD 

SYP POTCHLOR 10ml in 1 GLASS OF WATER PO TID 

BP MONITORING 2nd HRLY AND VITALS 4rth HRLY

18/12/22

ICU BED NO 2 

AGE 44

SEX MALE

S

NO FEVER SPIKES 

SLEEP NORMAL 

APPETITE IMPROVED 

STOOLS PASSED 

O

PT IS C/C/C

BP- 100/70mm HG

PR -109/min

SPO2 - 95 on ra

TEMP - 98F

GRBS: 114mg/dl

CVS - S1 S2 + NOMURMURS,JVP NOT RAISED 

RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA

OTHER AREAS- NVBS HEARD

P/A - SOFT NT,LIVER SPAN 9cm ON PERCUSSION TYMPANIC NOTE HEARD ,NO DULLNESS,BS + 

CNS - HMF INTACT 

FINE TREMORS PRESENT

SENSORY RT. LT

PROPRIOCEPTION. UL,LL. +. +

VIBRATION UL,LL. +. +

TOUCH UL,LL. +. +

PRESSURE UL,LL. +. +

REFLEXES B. T. S. K. A. PLANTAR 

RT ++. ++. +. ++. +. F

LT ++. ++. +. ++. +. F.  

RHOMBERG POSITIVE

GAIT NORMAL

CEREBELLAR SIGNS 

DYSDIADOKINESIA ABSENT 

HEEL KNEE -

INPUT -1650ML OUTPUT - 600ML

A

? ALCOHOLIC LIVER DISEASE 

BILATERAL MIDDLE LOBE CONSOLIDATION..? CAP.? TB

 BICYTOPENIA WITH ANEMIA UNDER EVALUATION. ? B12 DEFECIENCY SECONDARY TO ALCOHOL

WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)

P 

2 EGG WHITES

O2 INHALATION if O2 sat <90% 

(D3)INJ AUGMENTIN 1.2g IV BD 

INJ PAN 40 MG PO OD 

(D2)INJ THIAMINE 200mg IN 100ML NS IV BD 

OVER 30MIN 

(D1)INJ VIT B12 1500MICROGM IN 100ML NS IV OD 

TAB FOLIC ACID 1MG PO OD 

TAB UDILIV 300mg PO BD 

TAB PCM650 MG PO SOS 

SYP GRILLINCTUS 15ML PO TID 

SYP APTIVATE 15ml PO BD 

SYP POTCHLOR 10ml in 1 GLASS OF WATER PO TID 

INJ VIT K 1AMP +100ML NS OVER 10MIN 

TAB HEPAMERZ 500 mg PO OD 

BP MONITORING 2nd HRLY AND VITALS 4rth HRLY

 FOLLOW PSYCHIATRIC ORDERS 

T LORAZEPAM 2 MG (1-1-2)

TAB BACLOFEN XL 20MG PO OD HS 

TAB BENFOTAMINE 100MG PO OD 

ADEQUATE HYDRATION

19/12/22

19/12/22

WARD

AGE 44

SEX MALE

S

NO FEVER SPIKES 

SLEEP NORMAL 

SOB DECREASED,COUGH REDUCED 

STOOLS PASSED ONCE 

O

PT IS C/C/C

BP- 120/80mm HG

PR -100/min

SPO2 - 98 on ra

TEMP - 97.3F

GRBS: 120mg/dl

CVS - S1 S2 + NOMURMURS,JVP NOT RAISED 

RS - BAE + CREPTS + IN LEFT IAA AND LT.ISA

OTHER AREAS- NVBS HEARD

P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS + 

CNS -

RHOMBERG POSITIVE

GAIT NORMAL

MOTOR       UL LL

POWER. RT 5/5. 5/5

                LT 5/5. 5/5

TONE. RT .  N.      N

            LT.    N.       N

INPUT -1200ML OUTPUT - 1150ML

A

1)? ALCOHOLIC LIVER DISEASE 

2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB

3) WITH BICYTOPENIA UNDER EVALUATION. 

4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)

P 

2 EGG WHITES

(D4)INJ AUGMENTIN 1.2g IV BD 

(D2)INJ VIT B12 1500MICROGM IN 100ML NS IV OD 

SYP POTCHLOR 20ml in 1 GLASS OF WATER PO TID 

(D2)INJ VIT K 1AMP +100ML NS OVER 30MIN 

T OROFER XT PO BD 

T LORAZEPAM 2 MG (X-X-2)

TAB BACLOFEN XL 20MG PO OD HS 

TAB BENFOMET 100MG PO OD( X-1-X)

20/12/22

WARD

AGE 44

SEX MALE

S

NO FEVER SPIKES 

SLEEP NORMAL 

SOB DECREASED,COUGH REDUCED 

STOOLS PASSED ONCE 

O

PT IS C/C/C

BP- 90/60mm HG

PR -100/min

SPO2 - 96% on ra

TEMP - 97.3F

CVS - S1 S2 + NOMURMURS,JVP NOT RAISED 

RS - BAE + , CREPTS + IN LEFT IAA AND LT.ISA

INFRA MAMMARY AREA

OTHER AREAS- NVBS HEARD

P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS + 

CNS -

RHOMBERG POSITIVE

GAIT NORMAL 

MOTOR       UL LL

POWER. RT 5/5. 5/5

                LT 5/5. 5/5

TONE. RT.     N.    N 

            LT.    N.      N

A

1)? ALCOHOLIC LIVER DISEASE 

2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB

3) WITH BICYTOPENIA SECONDARY TO FOLIC ACID DEFECIENCY

4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)

P 

2 EGG WHITES

(D5)INJ AUGMENTIN 1.2g IV BD 

(D3)INJ VIT B12 1500MICROGM IN 100ML NS IV OD

SYP GRYLLINCTUS 15MLPO TID 

(D3)INJ VIT K 1AMP +100ML NS OVER 30MIN 

T OROFER XT PO BD 

T LORAZEPAM 2 MG (X-X-2)

(D4)TAB BACLOFEN XL 20MG PO OD HS 

TAB BENFOMET 100MG PO OD( X-1-X)

21/12/22

WARD

AGE 44

SEX MALE

S

NO FEVER SPIKES 

SLEEP NORMAL 

NO SOB ,NO COUGH 

STOOLS NOT PASSED 

O

PT IS C/C/C

BP- 90/60mm HG

PR -80bpm

SPO2 - 96% on ra

TEMP - 97.3F

RS - BAE + , IAA,ISA, MAMMARY CREPTS PRESENT

OTHER AREAS NVBS  

CVS - S1 S2 + NOMURMURS,JVP NOT RAISED 

P/A - SOFT NON TENDER, ON PERCUSSION TYMPANIC NOTE HEARD ,BS + 9/min

CNS -

RHOMBERG NEGATIVE

GAIT NORMAL 

MOTOR      UL LL

POWER. RT 5/5. 5/5

                LT 5/5. 5/5

TONE         RT N N

                    LT N N

A 

1)? ALCOHOLIC LIVER DISEASE 

2)WITH RIGHT MIDDLE LOBE CONSOLIDATION..? CAP.? TB

3) WITH BICYTOPENIA SECONDARY TO FOLIC ACID DEFECIENCY

4)WITH? ALCOHOL WITHDRAWAL SEIZURES (1EPISODE AT 1:30AM ON 17/12/22)(RESOLVED)

P 

2 EGG WHITES

(D3)INJ VIT B12 1500MICROGM IN 100ML NS IV OD

SYP GRYLLINCTUS 15MLPO OD 

T OROFER XT PO BD 

T LORAZEPAM 2 MG (1/2-X-2)

(D5)TAB BACLOFEN XL 20MG PO OD HS 

TAB BENFOMET 100MG PO OD( X-1-X

A CASE OF 65YEAR OLD MALE WITH VOMITINGS

 Name: K.SANNITH REDDY

Roll no. 65

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 a diagnosis and treatment plan.

Following is the view of my case :

65 YR OLD MALE WITH C/O VOMITINGS SINCE 2 MONTHS

PT WAS APPARENTLY ASYMPTOMATIC TILL 2YRS. THEN HE COMPLAINED OF GIDDINESS AND WENT TO LOCAL HOSPITAL AND WAS DIAGNOSED WITH HTN. SINCE THEN, HE IS ON AMLODIPINE 5MG 

HE HAS VOMITINGS SINCE 2 MONTHS AFTER EATING, NON PROJECTILE, NO FOUL SMELL, NON BLOOD STAINED ,SCANTY WHITISH IN COLOUR 

NO H/O FEVER, COUGH, BURNING MICTURITION, CONSTIPATION,HEADACHE

H/O WT LOSS ABOUT 10KG IN LAST 3 MONTHS

HE ALSO COMPLAINTS OF INABILITY TO WALK ON HIS OWN SINCE 2MONTHS ( SINCE VOMITINGS STARTED) 

BEFORE 2 MONTHS HE USED TO WALK ON HIS OWN AND HE IS FARMER BY OCCUPATION 

PAST H/O:

K/C/O HTN SINCE 2 YRS UNDER REGULAR MEDICATION (AMLO 5)

NOT K/C/O DM, CAD, CVA, EPILEPSY, TB, ASTHMA

PERSONAL H/O:

APPETITE NORMAL

DIET MIXED

SLEEP: ADEQUATE 

BOWEL AND BLADDER: REGULAR

NO KNOWN ALLERGIES

FAMILY HISTORY: NOT SIGNIFICANT 

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS ,COHERENT AND COOPERATIVE.

ORIENTED TO  PLACE, PERSON BUT NOT TIME

NO PALOR ,ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA

VITALS AT ADMISSION:

BP: 110/80MMHG

PR: 88BPM

RR: 18CPM

SPO2: 98%AT RA

TEMP 98°F

SYSTEMIC EXAMINATION:

CVS: S1,S2 HEARD

RS: BAE+

CNS: 

HIGHER MOTOR FUNCTIONS: 

Consciousness - conscious

Oriented time x  place ✓  person ✓

Speech and language - n

Memory

- immediate - retention  decreased

                         Recall       decreased

recent     decreased

remote  ✓

Delusions and hallucinations absent 

MMSE SCORE 25/30

CRANIAL NERVES       RIGHT LEFT 

CN 1     Normal 

CN 2.    Field of vision    ⬇️.      ⬇️       

              Colour vision.    N.       N       

CN 3 4 6    Extra ocular movements. N.      ⬇️

                Pupil size        NSRL.   NSRL 

 Direct, Indirect reflex   N.          N.  

               Accomodation. N.        N

                Ptosis             absent.    Absent 

                 Nystagmus.  absent.     Present

CN 5.    Sensory and motor reflexes normal 

               Jaw jerk   Absent 

CN 7 ,8 ,9,10,11,12.  Normal on both sides

MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5

CEREBELLAR SIGNS:

ATAXIA -  SWAYING TO LEFT

NYSTAGMUS PRESENT IN LEFT EYE TO THE LEFT 

NO DYSARTHRIA 

NO HYPOTONIA 

TITUBATION ABSENT 

NO INTENTION TREMOR 

PENDULAR KNEE JERK ABSENT 

UL   CORORDINATION 

FINGER NOSE TEST POSITIVE 

FINGER FINGER TEST POSITIVE 

(NO COORDINATION )

LL.  HEEL KNEE TEST

       Rt.          Lt

       ++.           - 

                                           RT.         LT

DYSDIADOKINESIA        +.             + 

MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5

REFLEXES ON BOTH SIDES:

B ++

T ++

S +

K +

A +

P F

P/A: SOFT, NON TENDER

INVESTIGATIONS:

HB: 14.9

TLC: 10,300

PLT: 3.56

RBC: 5.33

NA+: 130

K+: 3.9

Cl- 94

CA++: 0.93

LFT:

TB: 2.38

DB: 0.7

AST: 24

ALT: 13

TP: 6.9

ALB: 4.2

A:G: 1.53

SR CREAT: 1.3

BLOOD UREA: 56

SR OSM: 260

RBS: 90

BLOOD GRP: O+

USG ABDOMEN :  NO SONOLOGICAL ABNORMALITY

Chest xray : 

Xray abdomen erect : 

XRay of knee joint : 

MRI BRAIN : 

44x41x42mm Peripherally enhancing thick irregular wall intra axial lesion in left cerebellar hemisphere extending into vermis 

Lesion is causing compression and displacement of 4rth ventricle to contralateral side with resultant mild dilatation of lateral and 3rd ventricle suggestive of acute hydrocephalus

Periventricular hyperintensity suggestive of transependymal sepage of CSF 

PROVISIONAL DIAGNOSIS:

1.Chronic vomitings since 2 months secondary to ?lt Cerebellar lesion compressing 4th ventricle ? Acute hydrocephalus secondary Mets? Primary brain malignancy

2.k/c/o htn since 2 yrs with b/l OA knee grade 4, lt more than rt

TREATMENT:

17/12/22

INJ ZOFER 4MG IV TID

INJ PAN 80MG IN 50ML NS CONT IV INFUSION

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

GRBS 4TH HRLY

18/12/22

INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

PROCTOLYTIC ENEMA

GRBS 4TH HRLY

19/12/22

INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

TAB AMLONG 5MG PO OD

GRBS, BP 4TH HRLY

20/12/22

INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 30ML/HR

TAB SHELCAL CT PO OD

TAB JOINTACE PO OD

D2 INJ LEVERA 500MG IV BD

D2 INJ DEXA 8MG IV TID

GRBS, BP 4TH HRLY

A CASE OF 42 YEAR OLD MALE

K.Sannith Reddy -

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: K.SANNITH REDDY

Roll no: 65

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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

This is a case of 42year old male patient resident of Nalgonda came to the casualty with 

C/O HEADACHE ,BLURRING OF VISION AND WEAKNESS OF LOWER LIMBS SINCE 3 DAYS 

HEADACHE - OCCIPITAL AND VERTEX AND RADIATING , NO LOC ,NO H/O SIEZURES,PROJECTILE VOMITING -

+PRICKING TYPE OF PAIN 

A/W H/O FEVER 5 DAYS BACK A/W CHILLS AND RIGOR 

FEVER LASTED FOR 1 HR AND THEN SUBSIDED WITH MEDICATION 

BURNING MICTURITION +,VOMITING -, LOOSE STOLS -

PT WAS TAKEN TO PVT HSPTL MIRYALAGUDA FOR THE SAME AND WAS HAVING HIGH BP C/O BLURRED VISION EPISODIC LASTING FOR FEW MINUTES/SECONDS 

WEAKNESS OF LIMBS NON PROGRESSIVE 

PATIENT WAS DIAGNOSED OUTSIDE TO HAVE RENAL FAILURE WITH CREAT 5.1, UREA 113 BP 200/110 MMHG DIAGNOSED TO HAVE UNDIFF SEPSIS A/W AKI ON CKD WITH CONTRAST NEPHROPATHY 

CT BRAIN SHOWING RT LACUNAR INFARCT AND WAS REFFERED TO OUR HOSPITAL FOR HEMODIALYSIS

PAST HISTORY:

K/C/O OF HTN SINCE 1 YEAR under medication (unknown)

H/O CAD MILD DISEASE (ANGIOGRAPHY - 26/5/22)

NOT A K/C/O DM,ASTHMA,CAD,THY,EPILEPSY

Personal history:

Diet- Mixed

Appetite- Goo

Bowel and bladder movements- Regular

Sleep- Adequate

Family history

No significant family history

General Physical Examination

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative

well oriented to time, place and perso

well nourished and moderately built

NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY OEDEMA

VITALS

TEMP Afebrile

PR 76BPM

RR 16 CPM

BP: 160/100MM H

SPO2 98% 

GRBS 104MG/

SYSTEMIC Examination

CVS: S1 S2 HEARD NO THRILLS ,NO MURMUR

RS: BAE+,NVBS HEAR

  TRACHEA POSITION CENTRAL ,NO RHONCI,NO CREPT

P/A SOFT NON TENDER ,BS PRESENT

CNS:

PT IS CONSCIOUS

SPEECH IS Slurred

NECK STIFFNESS PRESENT ,KERNIGS SIGN ABSENT

TERMINAL NECK RIGIDITY PRESENT 

CRANIAL NERVES NORMAL

GAIT NORMAL

REFLEXES:    B.    T.    S.    K.     A.    PLANT

RIGHT.          ++   ++.    +     ++   +       F

LEFT.             ++    ++   +     ++   +        F 

MOTOR 

TONE:                       RIGHT.              LEFT 

UPPER LIMB            N.                        N

LOWER LIMB           N.                        N

CEREBELLAR SIGNS : ABSENT 

PROVISIONAL DIAGNOSIS: 

MENINGITIS SECONDARY TO ? BACTERIAL/?VIRAL 

WITH AKI (RESOLVING) WITH HFREF(EF 47%EF)

K/C/O HTN SINCE 1 YEAR 

INVESTIGATIONS: 

TEMPERATURE CHARTING : 

USG ABDOMEN DONE ON 9/12/22: 

GALLBLADER WALL IS EDEMATOUS WITH SLUDGE 

RAISED ECHOGENECITY OF B/L KIDNEY 

USG ABDOMEN AND PELVIS : on 15/12/22

CHOLELITHIASIS

NO CHOLECYSTITIS

GRADE I/II RENAL PARENCHYMAL CHANGES

MILD ASCITES

RENAL DOPPLER : on 15/12/22

CSF ANALYSIS: 

Vol: 0.5 ml 

Appearance : clear 

Colour : colourless

Tc : 70 cells

Dc : predominantly lymphocytes

RBC :nil

Other:nil

CSF CYTOLOGY: 

It shows scattered lymphocytes ,few monocytes

Against proteinaceous background

Impression : no evidence of atypical cells

CSF 

GLUCOSE :51mg/dl

PROTEIN :30mg/dl 

CHLORIDE:110mmol/L

CSF CBNAAT : NEGATIVE 

CSF C/S ON 12/12/22

NO GROWTH FOUND

BLOOD C/S ON 12/12/22 

NO GROWTH FOUND 

URINE C/S ON 12/12/22

NO GROWTH FOUND 

ECG: on 9/12/22

2D ECHO DONE ON 10/12/22 

SEVERE CONCENTRIC LVH+

RWMA +LAD HYPOKINETIC ,RCA WITH LCX HYPOKINESIA 

MILD AR+,TRIVIAL TR+,MR+

SCLEROTIC AV ,NO AS/MS

EF 44% RVSP 35MMHG 

MODERATE LV DYSFUNCTION 

MINIMAL PF+

NO DIASTOLIC DYSFUINCTION 

IVC SIZE 1.35 CM

MILD DIALTED L.A/L.V

TREATMENT GIVEN: on 11/12/22

IVF U.O +30 ML/HR 

INJ LASIX 40 MG IV/OD 

INJ DEXA 6 MG IV TID 

Inj CEFTRIAXONE 2g IV BD

INJ LABETOLOL 20mg BOLUS INFUSION @ 5MG/HR 

TAB NICARDIA10 MG PO OD if BP> 160/100mmHg

TAB PCM 650 MG PO SOS 

TAB ULTRACET PO  1/2 tab QID 

ICU 

ON 12/12/22

S

NO FEVER SPIKES 

NO HEADACHE 

NO BLURRING OF VISION 

CRT NORMAL

SKIN PINCH NORMAL

O 

PT IS C/C/C 

ORIENTED TO TIME PLACE AND PERSON 

SENSORIUM IMPROVED 

GCS -E4V5M6

BP 130/80 mm hg 

PR 88BPM REGULAR 

SAT -98% ON RA 

GRBS-159MG%

PEDAL EDEMA absent 

CNS -S1,S2 heard JVP NOT RAISED 

RS- BAE+ NVBS HEARD 

P/A SOFT NON TENDER 

CNS - HIGHER MOTOR FUNCTIONS INTACT 

SPEECH - N ,GAIT - N ,

                   B T. S. K. A. PLANTAR 

RIGHT ++. ++. +. ++. +. F

LEFT ++. ++ +. ++. +. F

A 

MENINGITIS SECONDARY TO ? BACTERIAL OR ?VIRAL 

with AKI (RESOLVING) WITH HFREF (47%EF)

with K/C/O HTN since 1 year (under unknown medication)

P

IVF U.O +30 ML/HR 

INJ LASIX 40 MG IV/OD 

INJ DEXA 6 MG IV TID 

Inj CEFTRIAXONE 2g IV BD

INJ LABETOLOL 20mg BOLUS INFUSION @ 5MG/HR 

TAB NICARDIA 20  MG PO TID 

TAB METXL 50mg po OD

TAB ARKAMINE 0.1MG PO QID

TAB PCM 650 MG PO SOS 

TAB ULTRACET PO 1/2 tab QID 

ICU 

ON 13/12/22

S

NO FEVER SPIKES 

NO HEADACHE 

NO BLURRING OF VISION

O 

PT IS C/C/C 

ORIENTED TO TIME PLACE AND PERSON 

SENSORIUM IMPROVED 

GCS -E4V5M6

BP 170/90 mm hg 

PR 89BPM REGULAR 

SAT -98% ON RA 

GRBS-165MG%

PEDAL EDEMA absent 

CVS -S1,S2 heard JVP NOT RAISED 

RS- BAE+ NVBS HEARD 

P/A SOFT NON TENDER 

CNS - HIGHER MOTOR FUNCTIONS INTACT 

SPEECH - N ,GAIT - N ,

                   B     T.    S.   K.   A.     PLANTAR 

RIGHT       ++.  ++. +.   ++.   +.      F

LEFT.          ++. ++  +.   ++.    +.      F

A 

MENINGITIS SECONDARY TO ? BACTERIAL OR ?VIRAL 

with AKI (RESOLVING) WITH HFREF (47%EF)

with K/C/O HTN since 1 year (under unknown medication)

P

IVF U.O +30 ML/HR 

TAB LASIX 40 MG PO/BD 

INJ DEXA 6 MG IV TID 

Inj CEFTRIAXONE 2g IV BD

TAB NICARDIA 20 MG PO TID 

TAB METXL 50mg po OD

TAB ARKAMINE 0.1MG PO QID

TAB PCM 650 MG PO SOS 

TAB ULTRACET PO 1/2 tab QID 

ICU ON 14/12/22

S

NO FEVER SPIKES 

NO HEADACHE 

NO BLURRING OF VISION

O 

PT IS C/C/C 

ORIENTED TO TIME PLACE AND PERSON 

SENSORIUM IMPROVED 

GCS -E4V5M6

BP 140/100 mm hg 

PR 88BPM REGULAR 

SAT -99% ON RA 

GRBS-186MG%

PEDAL EDEMA absent 

CVS -S1,S2 heard JVP NOT RAISED 

RS- BAE+ NVBS HEARD 

P/A SOFT NON TENDER 

CNS - HIGHER MOTOR FUNCTIONS INTACT 

SPEECH - N ,GAIT - N ,

                   B    T.    S.    K.     A.      PLANTAR 

RIGHT       ++. ++.  +.   ++.    +.        F

LEFT.          ++. ++  +.   ++.     +.        F

A 

MENINGITIS SECONDARY TO ? BACTERIAL OR ?VIRAL 

with AKI (RESOLVING) WITH HFREF (47%EF)

with K/C/O HTN since 1 year (under unknown medication)

P

IVF U.O +30 ML/HR 

TAB LASIX 40 MG PO/BD 

INJ DEXA 6 MG IV TID 

Inj CEFTRIAXONE 2g IV BD

TAB NICARDIA 20 MG PO TID 

TAB METXL 50mg po OD

TAB ARKAMINE 0.1MG PO QID

TAB PCM 650 MG PO SOS 

TAB ULTRACET PO 1/2 tab QID 

TAB TELMA40MG PO OD

BP CHARTING: 14/12/222

ICU ON 15/12/22

S

NO FEVER SPIKES 

NO HEADACHE 

NO BLURRING OF VISION 

O 

PT IS C/C/C 

ORIENTED TO TIME PLACE AND PERSON 

SENSORIUM IMPROVED 

GCS -E4V5M6

BP 200/100 mm hg 

PR 68BPM REGULAR 

SAT -98% ON RA 

GRBS-107MG%

PEDAL EDEMA absent 

CVS -S1,S2 heard JVP NOT RAISED 

RS- BAE+ NVBS HEARD 

P/A SOFT NON TENDER 

CNS - HIGHER MOTOR FUNCTIONS INTACT 

SPEECH - N ,GAIT - N ,

                   B T. S. K. A. PLANTAR 

RIGHT ++. ++. +. ++. +. F

LEFT ++. ++ +. ++. +. F

A 

MENINGITIS SECONDARY TO ? BACTERIAL OR ?VIRAL 

with AKI (RESOLVING) WITH HFREF (47%EF)

with K/C/O HTN since 1 year (under unknown medication)

P

Tab lasix 40mg po od 4pm

Tab Telma H 40/12.5mg po od at 8 am

Tab Minipres XL 2.5mg po od at 8 pm

Tab Met XL 50mg od at 2pm

Tab Cilnidipine 10mg po od 8pm

ICU

ON 16/12/22

S

NO FEVER SPIKES 

NO HEADACHE 

NO BLURRING OF VISION 

O 

PT IS C/C/C 

ORIENTED TO TIME PLACE AND PERSON 

SENSORIUM IMPROVED 

GCS -E4V5M6

BP 160/90 mm hg 

PR 62BPM REGULAR 

SAT -99% ON RA 

GRBS-141MG%

PEDAL EDEMA absent 

CVS -S1,S2 heard JVP  RAISED 

RS- BAE+ NVBS HEARD 

P/A SOFT NON TENDER 

CNS - HIGHER MOTOR FUNCTIONS INTACT 

SPEECH - N ,GAIT - N ,

                   B         T.         S.        K.      A.      PLANTAR 

RIGHT     ++.       ++.      +.         ++.     +.            F

LEFT       ++.       ++       +.          ++.     +.           F

A 

MENINGITIS SECONDARY TO ? BACTERIAL OR ?VIRAL 

with AKI (RESOLVING) WITH  HFREF (47%EF)

with K/C/O HTN  since 1 year (under unknown medication)

P

Tab lasix 40mg po od 4pm

Tab Telma H 40/12.5mg po od at 8 am

Tab Minipres XL 2.5mg po od at 8 pm

Tab Met XL 50mg od at 2pm

Tab Cilnidipine 10mg po od 8pm

Tab ULTRACET 1/2 tab po sos 

Tab PCM 650 mg po sos

CASE OF 68 YEAR OLD FEMALE

 

Sannith Reddy -65

68 Year old female

December 14, 2022

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: K.SANNITH REDDY

Roll no: 65

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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

This is a case of 68 years old female resident of nalgonda has come to the casualty with the chief complaints of

C/o breathlessness since 1 week

Cough since 1 week

Patient was aparently asymptomatic 1 week back then she developed breathlessness which is insidious in onset, MMRC grade 2 not associated with wheeze, palpitations, sweating, seasonal variation +

C/o cough since 1 week, non productive, seasonal variation 

No complaints of fever, chest pain, chest tightness, loss of weight, vomiting, diarrhoea

Loss of appetite +

H/o fall in bathroom 10 days back, no head injury

Past history

H/o similar complaints in the past, 5 years back

Hospital admission + and taken treatment

Inhaler usage 2 years back for 1 month and later stopped

Nebulization taken since 1 week (2-3 times)

Known case of HTN since 10 years on medication (Tab. Telma H 40/12.5 OD)

Drug usage- Tab. Montelukast OD since 5 years

Tab. Prednisolone OD since 5 years

Known case of ?hypothyroidism since 4 years not using medication

Not a known case of DM, epilespsy, CAD

No past h/o TB

No h/o any previous surgeries

No known allergies

Personal history:

Diet- Mixed

Appetite- Good

Bowel and bladder movements- Regular

Sleep- Adequate

Family history:

No significant family history

General Physical Examination:

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative

well oriented to time, place and person

well nourished and moderately built

Pallor- Absent

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema- Absent

Vitals

Temperature- 98.8F

Blood pressure- 110/70 mm of Hg

Pulse rate- 98 bpm

Respiratory rate- 21 cpm

SpO2- 96% at 2 lit O2

GRBS- 141 mg%

Systemic Examination:

Cardiovascular system:

S1 and S2 sounds are heard

Respiratory system:

Inspection

Shape of chest- Elliptical

B/L symmetrical chest

Trachea appears to be central

Expansion of chest equal on both sides

No accessory muscles of respiration in use

No drooping of shoulders

No wasting of muscles

No crowding of ribs

Spinoscapular distance equal on both sides

Apical impulse couldn't be seen

Palpation

All inspectory findings are confirmed

No local rise of temperature

No tenderness

Trachea central

Chest movements equal on both sides

Apex beat- Left 5th intercoastal space medial to MCL

TVF- Equal on both sides

Percussion

Direct- Resonant 

Indirect- Resonant

Auscultation

BAE +

Crpets + in right IAA, ISA

Rhonchi + B/L ISA, infra SA, ICA, IAA

Abdominal Examination:

Shape of Abdomen is scaphoid

Soft and non tender

Bowel sounds are heard

No palpable mass

Hernial orifices are normal

No organomegaly

Central Nervous System:

No focal neurological deficits

Provisional diagnosis

Acute exacerbation of ?Asthma ? COPD ?ILD ?Miliary TB ?CAP with Hyponatremia (Resolved) Hypokalemia(Resolving) (Hypovolemic) 

with septic shock (Resolving)

HTN + since 1 year (Under Tab. Telma H stopped)

with hypothyroidism (not under medication)

Temperature charting

Investigations

4/12/22

CBP

Hb- 10.1 gm/dL

TC- 18500 cells/cumm

Platelet count- 3.32 lakhs/cumm

Blood urea- 52 mg/dL

Serum creatinine- 0.9 mg/dL

Serum electrolytes

Na+ - 123 mE/L

K+ - 3.3 mEq/L

Cl- - 82 mEq/L

Ca2+ - 0.83 mmol/L

Liver function tests

TB- 1.5 mg/dL

DB- 0.36 mg/dL

SGOT- 12

SGPT- 10

ALP- 139

Total proteins- 5.7

Albumin- 2.1

A/G ratio- 0.62

Serum uric acid- 4.7 mg%

Blood sugar random- 102 mg/dL

ABG

PH- 7.54

PCO2- 27.8 mmHg

PO2- 61.6 mmHg

HCO3- 23.8 mmol/L

O2 sat- 93.5%

Anti HCV antibodies- Rapid- Non reactive

Anti HCV antibodies- elisa- Non reactive

HBsAg ELISA- Negative

HBsAg Rapid- Negative

HIV 1 & 2 ELISA- Non reactive

HIV 1/2 Rapid test- Non reactive

Serum osmolality- 254 mOSM/Kg

Urine sodium- 125 mmol/L

Urine potassium- 26.9 mmol/L

Urine chloride- 149 mmol/L

Chest x ray PA view

ECG

2D ECHO

5/12/22

Hemogram

Hb- 9.1 mg/dL

TC- 18100 cells/cumm

PLT- 3.03 lakhs/cumm

Lipid profile

TC- 96 mg/dL

TG- 81 mg/dL

HDL cholesterol- 30 mg/dL

LDL cholesterol- 74 mg/dL

VLDL- 16.2 mg/dL

Serum electrolytes

Na+ - 127

K+ - 3.7

Cl- 91

Ca2+- 0.90 mmol/L

Thyroid profile

T3- 0.75 ng/ml

T4- 7.86 micro g/dL

TSH- 3.88 micro lu/ml

ABG

PH- 7.38

PCO2- 41.7 mmHg

PO2- 40.2 mmHg

HCO3- 24.4 mmol/L

O2 sat- 79.6 %

Blood urea- 50 mg/dL

Serum creatinine- 1.2 mg/dL

6/12/22

Hemogram

Hb- 10 mg/dL

TC- 18400 cells/cumm

PLT- 3.71 lakhs/cumm

ABG

PH- 7.432

PCO2- 32.8 mmHg

PO2- 141 mmHg

HCO3- 21.5 mmol/L

O2 sat- 97.6 %

Blood urea- 50 mg/dL

Serum creatinine- 0.9 mg/dL

Serum electrolytes

Na+ - 130

K+ - 3.4

Cl- 94

Ca2+- 0.90 mmol/L

Chest xray

7/12/22

Hemogram

Hb- 8.7 mg/dL

TC- 9000 cells/cumm

PLT- 2.91 lakhs/cumm

Blood urea- 30 mg/dL

Serum creatinine- 0.8 mg/dL

Serum electrolytes

Na+ - 133

K+ - 3.7

Cl- 99

Ca2+- 0.88 mmol/L

8/12/22

Hemogram

Hb- 7.5 mg/dL

TC- 6700 cells/cumm

PLT- 2.59 lakhs/cumm

Blood urea- 41 mg/dL

Serum creatinine- 0.8 mg/dL

Serum electrolytes

Na+ - 134

K+ - 3.6

Cl- 103

Ca2+- 0.96 mmol/L

Chest x ray

Treatment

5/12/22

1. IVF NS @ 50 ml/hr

2. Inj. PIPTAZ 4.5 g IV TID

3. O2 inhalation to maintain SPO2 > 94%

4. Inj. PAN 40 mg IV OD BBF

5. Syp. Grillintus 2 tsp BD

6. Syp. Aristozyme 5 ml BD

7. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly

8. Tab. Montek LC PO HS

9. Monitor vitals

10. Inform SOS

5/12/22

1. IVF NS @ 125 ml/hr

2. Inj. PIPTAZ 4.5 g IV TID

3. O2 inhalation to maintain SPO2 > 94%

4. Syp. POTCHLOR 15 ml/ 20 mEq in 1 glass of water PO TID

5. Inj. PAN 40 mg IV OD BBF

6. Syp. Grillintus 2 tsp BD

7. Syp. Aristozyme 5 ml BD

8. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly

9. Tab. Montek LC PO HS

10. Inj. Noradrenaline 1 amp + 44 ml NS at 5 ml/hr according to BP 

11. Tab. Azithromycin 500 mg PO OD

12. Inj. Hydrocortisone 100 mg IV BD

13. Monitor vitals

14. Inform SOS

6/12/22

1. IVF NS @ 125 ml/hr

2. Inj. PIPTAZ 4.5 g IV TID

3. O2 inhalation to maintain SPO2 > 94%

4. Syp. POTCHLOR 15 ml/ 20 mEq in 1 glass of water PO TID

5. Inj. PAN 40 mg IV OD BBF

6. Syp. Grillintus 2 tsp BD

7. Syp. Aristozyme 5 ml BD

8. Nebulisation with Ipratropium 6th hrly, budecort 12th hrly, mucomist 12th hrly

9. Tab. Montek LC PO HS

10. Inj. Noradrenaline 2 amp + 44 ml NS at 4 ml/hr according to BP 

11. Tab. Azithromycin 500 mg PO OD

12. Inj. Hydrocortisone 100 mg IV BD

13. Monitor vitals

14. Inform SOS

ICU

Day 4

S

Fever spikes -

Stools Passed +

Skin pinch normal

Cough -

O

Patient is conscious, coherent, cooperative

Temp- 98.4 F

BP- 110/60 mmHg

PR- 78 bpm

RR- 20 cpm

SPO2- 93% on RA

GRBS- 130 mg/dL

CVS- S1, S2 +

RS

BAE +

Trachea- Central

                                       Rt. Lt

Supraclavicular. Rhonchi. Clavicular

Clavicular. Crackles, crepts. Crepts, rhonchi

Infraclavicular. Rhonchi. Rhonchi

Mammary. Crepts. Crepts&Rhonchi

Axillary. Rhonchi. Crackles

Infra axillary. Rhonchi, crackles. Crackles

Inter scapular. Crackles. Crepts, rhonchi

Infra scapular.Crackles,crepts.Crackles, crepts

P/A- Soft, Non tender

CNS- HMF+

Hemogram

Hb- 7.5 mg/dL

TLC- 6700 cells/cumm

RBC- 2.98 millions/cumm

PLT- 2.59 lakhs/cumm

Serum electrolytes

Na+ 134 mEq/L

K+ 3.6 mEq/L

Cl- - 103 mEq/L

Ca2+ - 0.96 mmol/L

A

Acute exacerbation of ? Asthma ? COPD

? ILD ? Miliary TB ? CAP

With hyponatremia (Resolved) Hypokalemia (Resolving) (Hypovolemic)

with septic shock (Resolving)

HTN+ since 1 year (Under Tab. Telma H Stopped)

With hypothyroidism (Not under medication)

P

1. IVF NS @ 100 ml/hr

2. Inj. PIPTAZ 4.5 g IV/TID (Day 4)

3. Inj. Hydrocortisone 100 mg IV BD (Day 3)

4. Inj. PAN 40 mg IV OD BBF

5. Inj. Noradrenaline 2 amp + 44 ml NS at 2 ml/hr according to BP to maintain MAP >65 if BP less than 80/50 mmHg

6. Tab. Montek LC PO BD

7. Tab. Azithromycin 500 mh PO OD (Day 3)

8. Tab. Pulmo clear 100/600 PO BD

9. Syp. POTCHLOR 20 mEq (15 ml) in 1 glass water PO TID

10. Syp. Grillinctus 10 ml PO BD

11. Syp. Aristozyme 5 ml PO BD

12. Nebulization with 

Ipratropium - 6th hrly (QID)

Budecort - 12th hrly (BD)

Mucomist- 12th hrly (BD)

13. O2 inhalation to maintain saturation >90%

14. Monitor vitals

15. Strict I/O charting

16. Inform SOS

 14/12/2022

ICU BED NO.1 

AGE :68 GENDER :F

S

NO FEVER SPIKES 

NO HYPOGLYCEMIA 

O

pt is conscious 

GCS- E4V5M6

B/L PEDAL EDEMA GRADE 1

BP 130/80MM HG 

PR 120bpm IRREGULARLY IRREGULAR

SAT 91% ON RA ,98@2LIT O2

RR 22 CPM

GRBS-171mg/dl

CVS -S1 S2 HEARD ,NO ADDED MURMURS 

P/A SOFT ,NON TENDER,BOWEL SOUNDS HEARD 

CNS: NO FOCAL NEUROLOGICAL DEFECIT 

RS: 

BAE+ 

ON AUSCULTATION : 

                                             RIGHT.                LEFT

SUPRACLAVICULAR.        crepts.      N vesicular 

INFRACLAVICULAR decreased bs.     N vesicular 

AXILLARY.                         crepts. crepts 

INFRAAXILLARY.             fine crepts. fine crepts 

MAMMARY.                       fine crepts NVBS

Blood urea - 54mg/dl

Serum creat -1.0 mg/dl

Serum electrolytes : 

Sodium -140mEQ/dl

Pottasium - 3.2mEQ/dl

Chloride -103 mEQ/dl

Calcium ionized- 0.92mmol/L

Chest xray 

 ECG: 

A

ACUTE EXACERBATION OF ASTHMA 

with? COMMUNITY ACQUIRED PNEUMONIA ? VIRAL 

with? OLD PULMONARY KOCHS 

WITH HYPONATREMIA (RESOLVED) HYPOKALEMIA (RESOLVING) WITH SEPTIC SHOCK (RESOLVED) 

WITH ANEMIA OF CHRONIC DISEASE 

WITH BRONCHIECTASIS OF B/L LOWER LOBE AND RT MIDDLE LOBE 

WITH PSVT (REVERTED) WITH ?MAT 

WITH HFPEF 

 

P

1)IVF NS @ UO+ 30ML/HR 

2)INJ PAN 40 MG IV BBF 

3)TAB PULMOCLEAR (100/60) PO BD 

4)TAB MONTEK LC PO OD 

5)SYP GRILLINCTUS Dx 2 TBSP 10 ML PO SOS

6)NEBULIZATION IPRATROPIUM-6TH HRLY , BUDECORT-12TH HRLY , MUCOMIST- 12TH HRLY 

7)TAB MET XL 50 MG PO OD 

8)O2 INHALATION MAINTAIN SAT > 94% 

9)MONITOR VITALS AND GRBS 

10)INTERMITTENT NIV 4RTH HOURLY 

11)CHEST PHYSIOTHERAPY