A 58 year old male patient elog


Lahari Karnakantoju

Roll no 61, 3 semester

Under the guidance of Dr.Krupa.( Intern)

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

I have 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.

★ CASE SCENARIO :

•A 58 year old male patient came to casualty with  chief complaints of:

- lower abdominal pain: 1 week

 -burning micturation:1week

- low back ache after lifting weights

-dribbling / decrease of urine out put:1week

-fever :1 week

- SOB , rest :1week

1. COMPLAINTS AND DURATION:

-week back , after weight lifting 

Patient had sudden onset of pain in abdomen 

By burning micturation with high fever : grade associated with chills and rigor 

Decrease urine output associated with SOB (grade -4)

With no H/O chest pain, palpitations, pedal oedema, facial puffiness.

2.HISTORY OF PRESENT ILLNESS

-H/O NSAISD use present,  Regularly for body pains and headache 

-No photo phobic, phonophobia , giddiness nausea, vomiting, tinnitus

- blurring of vision, black outs

3.HISTORY OF PAST ILLNESS

RTA 13 years, trauma to head , CT brain

Shows minimal bleed - used medication for 3 months 

K/C/O - HTN:  1 year (not on medication)

N/K/C/O- DM-2 ,TB, epilepsy ,CNA ,CAD


4.TREATMENT HISTORY : 

Diabetes-No

Hypertention- No

CAD-NO

Asthma -No

Tuberculosis -No

Antibiotics - No

Hormones-No

Chemo/Radiation -No

Blood Transfusion -NO 

Surgeries - No

Other- No 

- There is no usage of drugs as now 

5.PERSONAL HISTORY : 

-  Married 

- Occupation : mechanic

- Apettite : Lost form 1 week

- A non vegetarian

- Bowels : irregular

- Micturition : abnormal 

- No H/O known drug allergies

-Alcohol : regular ( 3times a week)

-Tobacco -No

-Drug use -No

-Betel nut - No

-Betel Leaf (Pan) - No

6. FAMILY HISTORY :

- NAD 


PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION :

 - Pallor- NO 

- lcterus-NO

- Cyanosis-No.  

- Clubbing of fingers/toes- No

- Lymphadenopathy-No

-Oedema of  feet- No

- Malnutrition - No

-Dehydration -NO 

- No H/O pallor, cyanosis , lymphadenopathy , icterus , clubbing of fingers or toes , oedema of feet , dehydration

- Temperature : Afebrile 

- BP : 140/70mmHg 

- PR : 88bpm

- SPO2 : 95% at room air 

-GRBS:113 mg%

SYSTEMIC EXAMINATION:

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

-IVP increased

C) RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath Sounds : vesicular 

- Adventitious sounds : No 

D) ABDOMEN 

- Shape of abdomen : Obese

-tenderness present(in supra public pain RIF)

- No palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are not palpable

- Bowel sounds : yes 

- Genitals : Normal 

E) CNS 

- patient is conscious 

- speech is normal 

- No focal neurological defect is seen 

-Glasgow scale :15/15

★ REFLEXES 

- Plantars : flexor 

★  CEREBRAL SIGNS :

- Finger - nose and Knee - Heel are in coordination 


INVESTIGATIONS ORDERED :

 Hemogram , CUE , RFT , LFT , ECG , 2D Echo , Chest X-ray , FBS , PLBS ,HbA1C


SEROLOGICAL INVESTIGATIONS: ON 6/07/21

pH : 7.46

PCo2 : 36.6

PO2 : 81.8

HCO3 : 26.0

St.HCO3 : 26.8

SPO2 : 94.3

________

USG Abd : B/L Grade -1 RPD

Rigth:10×6cm

left:9.6×5cm

-mild hepatomegaly with Grade-1 fatty liver 

________

Hb-13.6

TLC-13,100

N-91

L-04

E-02

M-03

B-00

PLT(plateletcount)-1.26

________

Clinical Urine Examination:

Pus cells-4 to 6

Epithelial cells-3 to 4

Alb: Trace

________

Urine: plenty of pus cells

________

HbA1C : 6.8

________

RBS : 120mg/dl

________

Serum creatinine: 5.9 mg/ dl

Blood urea: 128 mg/ dl

Sodium : 133 mEq/L

potassium : 3.6 mEq/L

chloride : 53 mEq/L

_________

Liver Function Test:

TB   -1.63

DB   -0.48

AST -26

ALT  -30

Alkaline Phosphate-245

TP:5.5

Alb-2.9

A/G-1.17

__________

FBS-101




★ INVESTIGATIONS :

ON- 6/7/21 

-HbA1c :6.8%


-Random blood sugar :120mg/dl


-Serum electrolytes:

Na : 133mEq/L   (Normal range : 136-145)

K : 3.6mEq/L

Cl : 83mEq/L     (Normal range : 98-107)


-Blood urea:128mg/dl     (Normal range : 12-42)


-serum creatinine : 5.9mg/dl     (Normal range : 0.9-1.3)


Complete urine examination (CUE):

Colour: Pale Yellow 

Appearance: Clear

Reaction: Acidic

Specific gravity: 1.010

Albumin:Trace 

Sugar:Nil

Bile satls:Nil

Bile pigments :Nil

Pus cells : 4 to 6

Epithelial cells: 3 to 4

RBCs:Nil

Crystals :Nil

Casts: Nil

Amorphous deposits :absent 

Others: nil

The urine samples are send to pathology dept for CUE(complete urine examination)








ON - 7/7/21 

-BACTERIAL CULTURE AND SENSITIVITY REPORT:

Nature of specimen: Urine 

- plenty of pus cells (>10/HPF) seen

-culture report: Polymicrobial flora






ON- 8/7/21

-BACTERIAL CULTURE AND SENSITIVITY REPORT:

-Nature of specimen: Blood 

-1st S/C on 7/7

-culture report: No growth after 24 hours of incubation 






on 9/7/21

ABG report 

pH  :7.46

PCO2 : 36.6 mmHg

PO2 : 81.8 mmHg

HCO3 : 26.0 mmol/L

St.HCO3 : 26.8 mmol/L

BEB : 2.8 mmol/L

BEecf : 2.5 mmol/L

TCO2 : 49.8 VOL 

O2 Sat : 94.3%

O2 Count : 19.8 vol%


SARS -COV-2 Qualitative PCR:   Negative 


on 10/7/21

HbA1c : 6.5%

FBS : 101mg/dl

PLBS : 147 mg/dl   (Normal range:0-140)













ON 11/7/21:

-Serum Albumin : 2.8 g/dl    (Normal range:3.5 - 5.2)

-PBLS : 116  mg/dl

-Blood urea: 158  mg/dl  (Normal range : 12-42)

-Serum electrolytes:

  Na: 136mEq/L

  K: 3.6mEq/L

  Cl: 95mEq/L    (Normal range:98-107)

- Serum creatinine: 4.1 mg/dl  (Normal range : 0.9-1.3)

-Urinary Chloride: 183 mmol/L

-Spot urinary potassium: 11.8

-Spot urinary Sodium: 144 mmol/L

COMPLETE BLOOD PICTURE:

Hb-12.5 gm/dl    (Normal range : 13-17 gm/dl)

TLC-19,800 cells/cumm   (Normal range :4000-10000)

N-86   (Normal range : 40-80)

L-06   (Normal range :20-40)

E-02

M-06

B-00

PLT(plateletcount)-3.04

SMEAR: Normocytic normochromic with 
                neutrophils leucocytosis.

CUE:

Colour: Pale Yellow 

Appearance: Clear

Reaction: Acidic

Specific gravity: 1.010

Albumin:Nil

Sugar:Nil

Bile satls:Nil

Bile pigments :Nil

Pus cells : 1 to 2

Epithelial cells: 2 to 3

RBCs:Nil

Crystals :Nil

Casts: Nil

Amorphous deposits :absent 

Others: nil


ON 13/7/21:

- Blood urea: 89 mg/dl  [normal: 12-42]

- Serum creatinine: 2.3 mg/dl  [normal:0.9-1.3]

- 24Hr Urinary Creatinine :0.7 g/day

- 24Hr Urinary Protein : 98 mg/day

- 24Hr Urine volume : 3100 ml


ON 14/7/21:


HEMOGRAM:

* Hb – 11.4mg/dl     (Normal range : 13-17 gm/dl)

* Total count – 15,400cell/cumm   (Normal range :4000-10000)

* Neutrophils - 80% 

* Lymphocytes - 10%   (Normal range :20-40)

* Eosinophils - 04% 

* Monocytes - 06% 

* Basophils -00%

* PCV – 33.6VOl%    (Normal range : 40-50)

* MCV – 85.9fl 

* MCH - 29.2 pg 

* MCHC – 33.9% 

* RDW-CV – 13.5% 

* RDW-SD – 42.9fl 

* RBC COUNT – 3.91 millions/cumm    (Normal range :4.5-5.5)

* Platelet count – 4.3 lakhs /cumm 

* Smear 

- RBC – NORMOCYTIC NORMOCROMIC

- WBC - Leukocytosis

- Platelets - Adequate

- Hemoparasites - Not seen 

- impression - NORMOCYTIC NORMOCROMIC with Leukocytosis


★ PROVISIONAL DIAGNOSIS : 

-Acute kidney injury( AKI)  2° to UTI, associated with Denovo - DM -2

-With ? Right HEART FAILURE,

-With K/C/O - HTN ( Not on Rx)

- AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body.


TREATMENT:

1)IVF : -RL  @ UO+ 30ml/hr

            -NS

2)SALT RESTRICTION  < 2.4gm/day


3)INJ    TAZAR    4.5gm  IV/TID

                                 |

                             2.25gm IV/ TID

4)INJ     PANTOP 40mg  IV/OD


5)INJ     THIAMINE  1AMP  IN  100ml   NS   IV/TID


6)INJ     HAI  S/C  ACC  TO   SLIDING SCALE

              8AM  -  2PM  -  8PM


7)SYP    LACTULOSE   15ml    PO/TID [ To maintain stools less than or equal to 2]


8) GRBS  - 6th Hourly


9) BP/PR/TEMP - 4th Hourly


10) I/O - CHARTING


ON 10/7/21 :


1)IVF : -RL  @ UO+ 30ml/hr

            -NS

2)SALT RESTRICTION  < 2.4gm/day


3)INJ    TAZAR     2.25gm IV/ TID


4)INJ     PANTOP 40mg  IV/OD


5)INJ     THIAMINE  1AMP  IN  100ml   NS   IV/TID


6)TAB.   PCM   500mg    PO/ SOS


7)INJ     HAI  S/C  ACC  TO   SLIDING SCALE

              8AM  -  2PM  -  8PM


8)INFORM  GRBS 


9)GRBS  - 6th Hourly


10) BP/PR/TEMP - 4th Hourly


11) I/O - CHARTING (STRICT)


12)T. ULTRACET  PO 1/2 TAB  QID


-Foley's removed,

13)INPUT   UPTO   2 Liters only

                                                                } - I/O Charting 

14)Output monitoring should be done .





ON 12/7/21:








                                                             THANK YOU..



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