CBBLE UDHC similar cases

This is an online E log book to discuss our patient's 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 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 inputs on the comment box 

A 50 year old male patient is on maintainance haemodialysis since 10 months.

HOPI: patient was apparently asymptomatic 4yrs back and then developed shortness of breath (on and off), pedal oedema (pitting type).Later diagnosed as chronic renal failure and underwent dialysis twice weekly for about 10 months.

6 years back he met with an accident. His right leg got fractured and it took nearly 1 year to heal for which he used few medication continuously for 1 year.

PAST HISTORY:

 k/c/o HTN since 1 year.

Not a K/C/O of DM, thyroid disorders, TB

PERSONAL HISTORY:

He follows a mixed diet. Appetite -Normal, Bladder movements-normal,

Bowel movements-constipation since few weeks. Sleep- decreased.consumes alcohol regularly(90ml ) and stoped consuming1 year back.

He is a farmer and stopped working since 1 year.

FAMILY HISTORY: No significant family history.

DRUG HISTORY: No known drug allegies and patient uses Nicardia 10 mg.

GENERAL EXAMINATION : 

Patient is conscious ,coherrent, co operative and well oriented to his surroundings.he is poorly built and nourished.

no pallor ,no cyanosis, no icterus, no lymphadenopathy. bilateral pedal edema is seen and is of pitting type 

VITALS: 

Temperature: afebrile

Pulse rate: 98 bpm

 Respiratory rate: 19 cpm

 Bp: 190/100.Spo2: 99 

SYSTEMIC EXAMINATION: 

CVS: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs.

S1& S2 heard.

RESPIRATORY SYSTEM: no dyspnoea, no wheeze

Position of trachea- central, no adventitious sounds heard

CNS: patient is normal and conscious .reflex are normal.

CLINICAL IMAGES:

Investigations: 

RFT: urea-157.  Cr.10.2.   UA-9.8

USG- Rt Grade 3 RPD

          Lt  grade 2 RPD

2D ECHO:- trivial TR+ /AR+, no MR.

Good LV systolic function.

Diastolic dysfunction (+)

ECG:

LFT: 

T.b-0.9.  D.B- 0.2.  SGOT-17.    SGPT-15.    ALKP- 504.   TP-5.6.   ALB-3.6.   A/G RATIO-1.80

RFT: U-178.  CR-10.2.  U A-9.0. CALCIUM-9.4. P-4.5.  Na-140.   K-4.7.   Cl-102

S.iron 78

RBS- 70

CUE: ALB++.   SUGARS-TRACE.  RBC's, CRYSTALS, CASTS-NIL

HAEMOGRAM

HB-5.8.   TLC-7400.   LYMPHOCYTES -13

PCV-17.4.   RBC COUNT-2.01.  PLT-1.20.    

NORMOCYTIC NORMOCHROMIC ANEMIA WITH THROMBOCYTOPENIA.

PROVISIONAL DIAGNOSIS:

NSAID ASSOCIATED RENAL IMPAIRMENT.

TREATMENT: 

1) TAB.LASIX 40MG PO/BD

2) TAB.NICARDIA 10 MG PO/BD

3)TAB.NODOSIS 500MG PO/BD

4)TAB.OROFER -XT PO/OD

5)TAB.SHELCAL-CT PO/OD

6)INJ.ERYTHROPIEOTIN 4000IU S/C ONCE WEEKLY

7) SALT AND FLUID RESTRICTION.

CBBLE UDHC similar cases

This is an online E log book to discuss our patient's 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 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 inputs on the comment box

A 70 year old female home maker since 10-15 years (farmer by occupation) came to causality in drowsy state.

HOPI: Patient was apparently asymptomatic 10 years back ,then patient had h/o fall for which she went to local hospital there she got diagnosed with DM and since then she is on OHA medication(glim m2).4 years back she had h/o fall and went to hospital and got diagnosed with HTN. 1 session of dialysis was done (indication/cause unknown ) .Patient wasn’t on any medication for HTN .1 month back she developed hypoglycaemia secondary to OHA’s ,then resolved later.Patient had h/o fall 4 days back ,fracture of IT femur right leg operated(? ORIF done).On POD 2, patient was drowsy ,opening eyes to deep pain .Since yesterday ,she is unable to recognise patient attenders.

PAST HISTORY: 

K/C/O  DM since 10 years & on medication.

K/C/O HTN since 4 years

GENERAL EXAMINATION: 

O/E : Patient is responding to vocal commands

Pallor - present

Icterus  absent

Cyanosis - absent

Edema of feet - present

Lymphadenopathy  - absent

Clubbing - absent

VITALS:- 

 BP: 170/90mmhg

 PR: 98 bpm 

 RR: 25cpm 

 Spo2: 95%

 Grbs: 146

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : BAE present

P/A : soft 

CNS: Pt is drowsy.

tone : normal

INVESTIGATION:

12/2/22

D dimer: 6910ng/ml

BGT: B POSITIVE

ESR :. 140

RBS: 220

APTT: 30 seconds

PT : 15 seconds

INR: 1.11

USG abdomen 

ECG 

CT BRAIN 

VENOUS DOPPLER OF RIGHT LOWER LIMB

LFT 

PROVISIONAL DIAGNOSIS:

? uraemic encephalopathy with pre renal AKI with POD 4 right femur fracture ?CRIF + PFM with DM and HTN

TREATMENT:

1. INJ. Lasix 40mg IV/BD

2. INJ. HAI SC/TID 

3. INJ. CEFTRIAXON 1g/IV/BD

4. INJ. CLINDAMYCIN 600mg/ IV /TID

5.INJ. CLEXANE 20 mg SC/OD

6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD

7.TAB. Amlong 10mg PO /OD

8.IVF NS UO + 30 ml/hr

SOAP NOTES:-

DAY 2: 

S:- Patient opening eyes spontaneously

1 session of dialysis done yesterday on 13/2/22.

O:- 

TEMP:- AFEBRILE

PR:- 104bpm

BP:- 140/ 80mmhg

GRBS: 123MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- SOFT , NON TENDER

I/O: 2600/1540

A:- Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced with POD 5 right femur ? CRIF + PFN with DM &HTN 

P:-

INJ. MONOCEF 1GM/IV/BD

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR

Day 3:

S:- c/o fever spike

c/o 2-3 episodes of bilious vomitings .

1 session of dialysis done yesterday on 14/2/22

O:- 

TEMP:- 101 F 

PR:- 92bpm

BP:- 140/ 60mmhg

GRBS: 123MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 2400/2600

Stools : not passed

A:- Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced with POD 6 right IT femur ? CRIF + PFN with DM &HTN 

P:-

INJ. MONOCEF 1GM/IV/BD

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO+ 30ML/HR

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.

Day 4:

S:- c/o fever spike yesterday 

O:- 

TEMP:- 98.4 F 

PR:- 96 bpm

BP:- 150/ 90mmhg

GRBS: 245MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 2100/3200

Stools : passed 

A:-  Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced ?dehydration with POD 7 right IT femur ? CRIF + PFN with DM &HTN 

Surgery referral done i/v/o abdominal distension and vomiting, DIAGNOSIS: ? ADYNAMIC INTESTIONAL OBSTRUCTION, suggested CT ABDOMEN . 

P:- SOAP WATER  ENEMA DONE 

(DAY 1)INJ. PIPTAZ 4.5 GM/IV/STAT

                        | 

          PIPTAZ 2.25 GM/IV/BD 

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO + 30ML / HR 

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.

Day 5:

S:- c/o abdominal pain and right femur pain.responding to commands. 1 session of dialysis yesterday on 16/2/22 and ortho dressing has been done 

O:- 

TEMP:- 100.4F 

PR:- 94bpm

BP:- 180/100mmhg

GRBS: 123MG/DL

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 2400/3000

Stools :  passed,enema given 

A:-  Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 8 right IT femur ? CRIF + PFN with DM &HTN 

P:- 

(DAY 2)INJ. PIPTAZ 4.5 GM/IV/STAT

                        | 

          PIPTAZ 2.25 GM/IV/BD 

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

INJ. CLINDAMYCIN 600mg/ IV /TID

INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO + 30ML / HR 

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.

Day 6:

S:- c/o abdominal pain and right femur pain.responding to commands 

O:- 

TEMP:- 98.4F 

PR:- 90bpm

BP:- 140/100mmhg

GRBS: 223MG/DL @ 8am 

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- GUARDING PRESENT

I/O: 1700/2100

Stools :  passed 

A:-  Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 9 right IT femur ? CRIF + PFN with DM &HTN 

P:- 

(DAY 3) PIPTAZ 2.25 GM/IV/QID

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

(Day7)INJ. CLINDAMYCIN 600mg/ IV /TID

(Day7)INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO + 30ML / HR 

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.

 DAY 7:

 S:-  c/o pain in gluteal region since yesterday ,abdominal pain decreased and right femur pain decreased.responding to commands.

O:- 

TEMP:- 98.4F 

PR:- 90bpm

BP:- 130/90 mm hg

GRBS: 212MG/DL @ 8am 

CVS:- S1S2 heard , no murmurs

RS : BAE present

P/A:- soft 

I/O: 1650/2200

Stools :  passed 

Grade 1 bed sore at gluteal region 

A:-  Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 10 right IT femur ? CRIF + PFN with DM &HTN 

P:- 

(DAY 4) PIPTAZ 2.25 GM/IV/QID

INJ. LASIX 40 MG IV/BD

INJ. HAI SC/TID 

(Day8)INJ. CLINDAMYCIN 600mg/ IV /TID

(Day8)INJ. CLEXANE 20 mg SC/OD

TAB. Amlong 10mg PO /OD

IVF NS UO + 30ML / HR 

INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.

          Grade 1 bed sore at gluteal region 

36 YEAR OLD FEMALE WITH ? MIGRAINE WITH AURA

This is an online E log book to discuss our patient's 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 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 inputs on the comment box

36 year old female came to OPD with chief complaints of:- 

inability to perceive sensations of pain and temperature all over her body since 6 months.

History of presenting illness:-

She was apparently asymptomatic 3 years back ,the she started developing chest pain associated with sensation of cold all over body.

1 month back when she was holding a candle, she couldn't feel how hot it was, while cooking she is unable to feel the hot utensils.

3 days back she had improved sensation after medication (PREGABALIN)

She has history of giddiness (non rotational), complaints of off balance associated with blurring of vision, headache (right temporal region dragging type), aura +, photophobia +

No h/o seizures, disorientation, speech disturbances

No h/o nausea, vomiting, lacrimation or syncopal attacks

Past history:-

Patient was born in 1986, her paediatric history is unremarkable.

Her obstetric history involves 3 surgeries in the years 2008, 2012 and 2015 and 

One episode of amenorrhea in 2018.

In 2008 she had her first LSCS, and was diagnosed with eclampsia, there was 1 episode of seizures during labor, otherwise it was a full term delivery.

In 2012 she had yet another LSCS, as she had pre eclampsia, the LSCS was done 2 weeks prior to full term, she had a girl child 2.5 Kgs birth weight. 

In 2015 when she was 12 weeks far, she had a history of fall (slipped) and later had bleeding PV, for which her obstetrician advised abortion due to her history of eclampsia.

In 2019 she experienced chest pain associated with sudden onset sob, she was rushed to KIMS NKP, where she was diagnosed with HTN for which she was given TELMA 40 mg and was advised for admission (hypertensive urgency) , but left against medical advice.

In 2021 she started experiencing chest pain associated with cold sensation all over the body since 2 months. She had 2 - 3 episodes last month. Last episode being on - 2/2/22.

She doesn't have any h/o DM, BA, CAD, CVA, Hypothyroid / Hyperthyroid issues, 

She has had HTN since 2 years (2019) for which she takes TELMA 40 mg 

Personal history:-

She is a married woman with 2 children. She is a home-maker, she has no addictions, her appetite is normal, as are her bowel and bladder movements. Her diet is mixed.

Family history:-

No relevant history.

General examination:-

Patient is c/c/c/, moderately built, moderately nourished.

Pallor- absent 

Icterus- absent

Clubbing- absent

Koilonychia- absent

Lymphadenopathy- absent

Edema- absent

Vitals:-

PR - 85BPM

BP - 140/100 mmhg

RR - 20CPM

TEMP - 98.3 F 

Systemic examination:-

CVS - S1, S2 +, no murmurs, no visible precordial bulge, no JVP.

RS - BAE+, NVBS heard, no adventitious breath sounds heard.

P/A - scaphoid, soft, non tender, BS +

CNS -

Patient is alert, conscious, HMF intact.

Cranial nerves - intact.

Motor system examination:-

attitude of B/L UL & LL - normal.

bulk of all four limbs - normal.

tone of all four limbs - normal.

power of B/L UL - normal; power is reduced (4-/5) in B/L LL 

deep tendon reflexes - 

                     Rt      Lt

biceps -       1+       1+

triceps-        1+       1+

supinator-     -         -

knee-            -         -

ankle-           -         -

plantar-        mute  mute

superficial reflexes -

corneal reflex - present

conjunctival reflex - present

Sensory system examination:-

fine touch, crude touch +

pain and temperature - reduced.

vibration and proprioception intact.

cerebellar functions intact, no choreo-athetoid movements

no extra pyramidal symptoms.

gait - normal.

Autonomic system:-

No autonomic symptoms. (irregular sweating/ micturition.....)

Investigations:- 

on 8/2/22:

Hb: 12.7gm/dl

TLC: 12,300 CELLS/CUMM

PLATELET: 3.79 LAKHS/CU.MM

SERUM CREATININE: 0.8MG/DL

SODIUM: 140 mEql

POTASSIUM : 4.3 mEql

CHLORIDE: 97 mEql

CUE: NORMAL

ECG:

 MRI:- NO ABNORMALITY IN BRAIN

          NORMAL  MR  VENOGRAM.                         EEG:- NORMAL