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 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
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