General medicine case discussion

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending     clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   

K. Tejarshini (Intern) 

42Year old male presented with complaints of, 

Abdominal pain since 4 Days

Decreased urine output since 4 Days

Constipation since 4 Days

Vomitings since 4 Days

History of presenting illness:

Patient was apparently asymptomatic 4 Days back then he complained of abdominal pain which is diffuse associated with vomitings which is bilious, non-projectile, greenish in color, associated with constipation, passed stools 3Days back. 

Patient also complained of decreased urine output since 3Days.

There is a history of continuous alcohol consumption since 10 Days without intake of food. 

Stiffness of joints yesterday night. 

No loss of consciousness, giddiness, fever. 

Past History:

Not a Known case of DM, HTN, Asthma, Epilepsy, CAD, CVA. 

PERSONAL HISTORY 

diet : mixed 

Appetite : decreasd since 10 days 

Sleep : addequate 

Bowel habits:irregular

bladder habits:regular 

addictions :- h/0 of alcoholic intake since 30 years (sara) 

FAMILY HISTORY : Not significant

ON EXAMINATION : 

Patient  is conscious, coherent, cooperative.

 pallor , clubbing, cyanosis , lymphadenopathy absent. Icterus:Present,B/L pedal edema present pitting type upto ankles. 

VITALS 

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

Rr-16cpm

Spo2- 99% on RA

Systemic Examination:

Cardiovascular System : S1, S2 heard, no murmurs

Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.

Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 

Per abdomen : soft, non tender. No organomegaly.

INVESTIGATIONS :- 

HEMOGRAM 

HB 11.4GM/DL 

TLC #23,200 

N/L/E/M/B. #85/07/#00/08/00

PCV #31.8

MCV 88.6

MCH 31.8

MCHC 35.8

RDW-CV #14.5

RDW-SD #47.7

RBC. #3.59

PLT. 62,000

CUE :- 

ALBUMIN ++

BILE SALTS AND PIGMENTS   NIL

PUS CELLS   NIL 

LFT :- 

TB  #14MG/DL

DB #13.20MG/DL

SGOT #94 IU/L 

SGPT #50 IU/L 

ALP.   # 224 IU/L

TP  # 4.9gm/dl 

albumin. #2.4gm/dl 

A/G RATIO. 0.96

RFT:

Blood urea #196

Serum creatinine #4.5

Serum electrolytes 

Sodium #119

Potassium #2.6

Chloride #94

Calcium #0.91

ABG:

PH 7.31

Pco2:18.1

Po2:109

Hco3:8.9

St. Hco3:12.5

Blood group:A+ve

APTT 35sec

PT:18sec

INR:1.33

ESR:0.5mm/1st hour

LDH #469

Serum osmolality:265.4mosm/kg

Urinary electrolytes:

Sodium 169

Potassium 15

Chloride 180

ECG:

USG Abdomen:

2D Echo:

Diagnosis:

SEPSIS with MODS-Thrombocytopenia, ALI, AKI, DCMP-SEPTIC/ALCOHOL INDUCED

HYPOKALEMIA. 

Treatment:

Inj. MEROPENEM 1gm iv stat F/b 500mg iv/BD

Inj. DOXY 100mg iv/BD

Inj. PAN. 40mg iv/OD

Inj. ZOFER 4mg iv/sos

Inj. NEOMOL 1gm iv/sis (if temp>101°f) 

Inj. LASIX 40mg iv/BD

inj. OPTINEURON 1amp in 100ml NS iv/OD

Tab. UDILIX 300mg  BD

SYP. HEPAMERZ 10ml TID

SYP. LACTULOSE 15ml HS

Inj. THIAMINE 200mg in 100ml NS iv/BD

30/12/22:

Soap notes
AMC
Bed no:5
UNIT-3
Dr. Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
Stools passed
No Fever spikes
O:
Temp- Afebrile 
Bp-110/70mm hg
Pr- 70bpm
Rr-16cpm
Spo2- 99% on RA
GRBS:112mg/dl
I/O charting:2400/950ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact
Per abdomen : soft, non tender. No organomegaly.
A:
SIRS (Resolved)with MODS-Thrombocytopenia, ALI(Resolving),AKI(Resolved),HYPOKALEMIA(RESOLVED) , HYPONATREMIA(RESOLVED).
DCMP-SEPTIC /ALCOHOL INDUCED.
P:
IVF 2 units-2unitsNS, 1Unit RL@75ml/hr
Inj. DOXY 100mg iv/BD
Inj. THAIMINE 200mg in 100ml NS iv/BD
SYP. LACTULOSE 15ml HS

31/12/23:

Soap notes
AMC
Bed no:5
UNIT-3
Dr. Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
Stools passed
No Fever spikes
O:
Temp- Afebrile 
Bp-120/70mm hg
Pr- 80bpm
Rr-19cpm
Spo2- 99% on RA
GRBS:115mg/dl
I/O charting:2000/900ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact
Per abdomen : soft, non tender. No organomegaly.
A:
SIRS (Resolved)with MODS-Thrombocytopenia, ALI(Resolving),AKI(Resolved),HYPOKALEMIA(RESOLVED) , HYPONATREMIA(RESOLVED).
DCMP-SEPTIC /ALCOHOL INDUCED.
P:
IVF 2 units-2unitsNS, 1Unit RL@75ml/hr
Inj. DOXY 100mg iv/BD
Inj. THAIMINE 200mg in 100ml NS iv/BD
SYP. LACTULOSE 15ml HS