Sunday, 27 November 2022

A 75 year old female patient with shortness of breath ,Bilateral pedal edema

This is an a online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt.
 
Chief complaints:
75 year old female patient was brought to casualty with chief complaints of: C/o shortness of breath since 10 days Bilateral pedal edema since 10 days Facial puffiness since 10 days H/o of palpitation 10 days

HOPI:

Patient was apparently asymptomatic 15 days back & then she developed fever - low grade, intermittent, decreased with Rx

Shortness of breath since 10days which was insidious in onset, gradually progressed from class 2-4, Orthopnea present

C/o palpitations since 10 days B/I pedal edema since 10 days which was
pitting type extending upto knee Facial puffiness present. 

No history of chest pain, syncope attack. No history of decreased urine output, abdominal distention. No other complaints 

Personal history:

Diet:mixed
Appetite:normal
Bowel and bladder movements:normal
Appetite : decreased
Sleep : adequate 
No additions

On examination:-

Pt is C/C/C well oriented to Time ,place and person 

Pallor : present



B/I pedal edema - pitting type extending

upto knees



No cyanosis,clubbing,or generalised lymphadenopathy 

Temp: 99F

PR: 130 

Bp: 150/90mmhg

RR: 32 cpm

Spo2: 88-92% on RA

CVS:JVP raisedApex beat - diffuse Parasternal heave +Palpable P2 +


S1 S2 +



RS: Barrel shaped chest, Trachea central
BAE+, B/I crepts +


P/A: soft nontender

CNS: NFND

Inspection-

Shape of abdomen normal

Umbilicus -central and inverted

No visible scars,sinuses,dilated veins

Hernial orifices normal 



Palpation -no local rise of temperature 

No Tenderness present 

No guarding,rigidity,rebound tenderness 

No hepatomegaly,spleenomegaly



Percussion-

Resonant 

Auscultation-

Bowel sounds +

INVESTIGATION:

Serology: Negative 

Hemogram:

Serum electrolytes:

LFT:

ABG:
serum creatinine:

Serum urea:

RBS:

APTT:
:-
2D ECHO

ECG:
ECG at the time of presentation

After Inj. Metaprolol 5 mg IV/stat

26/11/2022
27/11/22 
7.00 am
10.00pm
28/11/2022
29/11/2022
30/11/2022
1/12/2022


X-ray:


27 /11/22 

28/11/2022






25/11/22

NEW ADMISSION 
25/11/2022 
S:

75 year old female patient was brought to casualty with chief complaints of: C/o shortness of breath since 10 days Bilateral pedal edema since 10 days Facial puffiness since 10 days H/o of palpitation 10 days

O:PT IS C/C/C

BP-100/70 MM OF HG

PR: 116 BPM RS: BAE+ B/L BASAL CREPTS + IAA, IMA ++

CVS-S1,S2

P/A-SOFT

CNS-NAD

A- ATRIAL FEBRILLATION EITH HEART FAILURE

P:
1 PRBC TRANSFUSION DONE ON 25/11/2022
P:
1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION
2.INJ.LASIX 40 MG IV /BD IF SBP >= 110 MM OF HG
3. T.METXL 25 MG PO/OD
4.T.PAN 40 MG PO/OD
 5. T.ECOSPRIN AV 75/10 MG PO/ HS
6. INJ.CLEXANE 40 MG OD / IV 
7. T.DOLO 650 MG PO/SOS
8.NEB WITH IPRAVEN 8TH HRLY
BUDECORT
  

Case uptake from Murali (INTERNEE) TO  ME 

26/11/2022

26/11/2022
 S: 75 year old female patient was brought to casualty with chief complaints of  shortness of breath since 10 days Bilateral pedal edema since 10 days Facial puffiness since 10 days H/o of palpitation 10 days

O:PT IS C/C/C
BP-130/70 MM OF HG
PR: 85 BPM

 RS:
BAE+
B/L BASAL DIFFUSE CREPTS + IAA, IMA ++
CVS-S1,S2
P/A-SOFT
CNS-NAD

A- ATRIAL FEBRILLATION WITH HEART FAILURE WITH BICYTOPENIA (ANEMIA+THROMBOCYTOPENIA )

P:
1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION
2.INJ.LASIX 40 MG IV /BD IF SBP >= 110
MM OF HG
3. T.METXL 25 MG PO/OD
4.T.PAN 40 MG PO/OD
 5. T.ECOSPRIN AV 75/10 MG PO/ HS
6. INJ.CLEXANE 40 MG OD / IV 
7. T.DOLO 650 MG PO/SOS
8.NEB WITH IPRAVEN 8TH HRLY
BUDECORT 



27/11/2022

 S: 75 year old female patient was brought to casualty with chief complaints of  shortness of breath since 10 days Bilateral pedal edema since 10 days Facial puffiness since 10 days

PEDAL EDEMA SUBSIDED
SOB DECREASED
FACIAL PUFFINESS DECREASED 

O:PT IS C/C/C
BP-110/70 MM OF HG
PR: 120 BPM
RS:BAE+
B/L BASAL DIFFUSE CREPTS + IAA, IMA ++
CVS-S1,S2
P/A-SOFT
CNS-NAD
A- ATRIAL FEBRILLATION WITH HEART FAILURE WITH BICYTOPENIA( ANEMIA+THROMBOCYTOPENIA ) WITH COPD
P:
1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION
2.INJ.LASIX 40 MG IV /BD IF SBP >= 110 MM OF HG
3. T.METXL 25 MG PO/OD
4.T.PAN 40 MG PO/OD
 5. T.ECOSPRIN AV 75/10 MG PO/ HS
6. INJ.CLEXANE 40 MG OD / IV 
7. T.DOLO 650 MG PO/SOS
8.NEB WITH IPRAVEN 8TH HRLY
BUDECORT 



28/11/2022

 S: 75 year old female patient was brought to casualty with chief complaints of  shortness of breath since 10 days Bilateral pedal edema since 10 days Facial puffiness since 10 days

PEDAL EDEMA SUBSIDED
SOB DECREASED
FACIAL PUFFINESS DECREASED 

O:PT IS C/C/C
BP-80/50 MM OF HG
PR: 141 BPM
RS:
BAE+
B/L BASAL DIFFUSE CREPTS + 
CVS-S1,S2
P/A-SOFT ,NIN TENDER
CNS-NAD

A- ATRIAL FEBRILLATION WITH HEART FAILURE WITH BICYTOPENIA(ANEMIA+THROMBOCYTOPENIA ) WITH VOPD

1 PRBC TRANSFUSION DONE ON 25/11/2022
P:
1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION
2.INJ.LASIX 40 MG IV /BD IF SBP >= 110 MM OF HG
3. T.METXL 25 MG PO/OD
4.T.PAN 40 MG PO/OD
 5. T.ECOSPRIN AV 75/10 MG PO/ HS
6. INJ.CLEXANE 40 MG OD / IV 
7. T.DOLO 650 MG PO/SOS
8.NEB WITH IPRAVEN 8TH HRLY
BUDECORT

29/11/2022

75/F with PEDAL EDEMA & SOB

D.O.A: 24/11/11

S:
PEDAL EDEMA SUBSIDED
SOB DECREASED

O:
PT IS C/C/C
BP-110/70 MM OF HG
PR: 100 - 130 BPM IRREGULARLY IRREGULAR 
RS:
BAE+
B/L BASAL CREPTS + 
CVS-S1,S2
P/A-SOFT ,NON TENDER
CNS-NAD

A- ATRIAL FIBRILLATION WITH HEART FAILURE 
COPD 
BICYTOPENIA (ANEMIA+THROMBOCYTOPENIA) ?B12 DEFICIENCY

1 PRBC TRANSFUSION DONE ON 25/11/2022

P:
1.FLUID (1.5 L) & SALT(<2GM) RESTRICTION
2.INJ.LASIX 40 MG IV /BD IF SBP >= 110 MM OF HG
3. T.METXL 25 MG PO/BD
4. T.ECOSPRIN AV 75/10 MG PO/ HS
6. INJ.CLEXANE 40 MG SC/OD
7. T.WARFARIN 2 MG PO/OD @ 6.00 PM 
8. T.DOLO 650 MG PO/SOS
9.NEB WITH IPRAVEN 8TH HRLY
BUDECORT
at

15 year old male with Fever,Chills,rigor

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input
This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome
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 diagnosis and treatment plan. 
 
CHIEF COMPLAINTS: FEVER SINCE 15 DAYS ASSOCIATED WITH CHILLS AND RIGOR 
CONSTIPATION SINCE 4 DAYS
BLOOD IN URINE SINCE 3 DAYS
1 EPISODE OF BLACK COLORED STOOL - 3 DAYS BACK

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK , THEN HE DEVELOPED HIGH GRADE FEVER ASSOCIATED WITH CHILLS AND RIGOR WITH EVENING RISE OF TEMPERATURE.
1 EPISODE OF VOMITING
BLOOD IN URINE SINCE 3 DAYS
1 EPISODE OF BLACK COLORED STOOLS - 3 DAYS BACK
NO H/O COLD,COUGH, BLEEDING FROM GUMS
NO H/ O BURNING MICTURITION

PAST HISTORY: NOT A KNOWN CASE OF HTN/DM/ASTHMA/CAD/EPILEPSY.
PERSONAL HISTORY : SINGLE, STUDENT 
APPETITE - NORMAL
DIET- MIXED
BOWELS- REGULAR
MICTURITION - NORMAL
 BLOOD IN URINE
NO KNOWN ALLERGIES
NO ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT
PHYSICAL EXAMINATION: NO PALLOR, ICTERUS,CYANOSIS, CLUBBING, LYMPHADENOPATHY,ODEMA.

VITALS AT THE TIME OF ADMISSION: 
TEMP: 102.8 F
PR:128 BPM
BP- 100/80 MM OF HG
RR: 20 CPM
GRBS: 119  MG/DL
 SYSTEMS EXAMINATION 
CVS: S1,S2 HEARD
 NO THRILLS,NI MURMURS
RS: TRACHEA- CENTRAL
BAE+
NVBS
P/A : SCAPHOID,NO TENDERNESS
NO ORGANIMEGALY
BOWEL SOUNDS HEARD.

CNS: 
CONCIOUS
SPEECH- NORMAL
NO MENINGIAL IRRITATION
(CRANIAL NERVES,MOTOR SYSTEM, SENSORY SYSTEM ) - INTACT 
REFLEXES
 
                                  RIGHT                        LEFT
BICEPS-                         +                                +
TRICEPS-                       +                                +
SUPINATOR-                 +                                +
KNEE-                            +                                +
ANKLE-                         +                                +
PLANTAR-                    +                                +
 
PROVISIONAL DIAGNOSIS: PYREXIA WITH THROMBOCYTOPENIA



INVESTIGATIONS: 





 DIAGNOSIS: VIRAL PYREXIA WITH THROMBOCYTOPENIA

TREATMENT: 
1. IV FLUIDS NS ,RL @100 ML /HR
2. T.DOLO 650 MG PO/TID
3.INJ.NEOMOL 1 GM IV/SOS 
IF TEMP >= 101 F


at

Friday, 25 November 2022

INTERNSHIP ASSESMENT OF GEN MED POSTINGS

This is
 THANMAI DASAROJU from 2017 batch posted in General medicine department from 12 th October to 11th December 2022

for the first 8 days i have been posted in 
NEPHROLOGY 

During this time i have assisted in central line insertion under the guidance of 
Dr. Bharath sir
Dr. Raveen sir
Dr. vamshi sir
Have learnt the proceedure for the central line placement  
Have witnessed few complications that may arise during the procedure and learnt from them.
i have learnt CPR on a patient who went into cardiac arrest. Unfortunately we couldn't revive the patient . Got shattered as it was my first patient but eventually learned to detach from humanly emotions and to do my duty. learnt how to convey bad news to Patient's attenders.

I have also learnt how a simple misunderstanding could kill a patient, as i was confused with NTG and Lasix vials. 
would have lost my patient if i hadn't been vigilant. 
Thanks to the Sister working at dialysis for pointing out my Mistake.

Seen CRF, AKI cases and learnt their management . 

For Next 7 days i have DONE ICU duties 

 most of the time my work was just monitoring.
but yet i tried to learn whenever i got time.
i learnt  how to take ABG samples with the help of Dr.Pavan sir and Dr. Shashikala ma'am 
i have also done RYLES tube insertion under Dr.shashikala ma'am guidance
i have done FOLEYS  catheterization under Dr.shashikala ma'am guidance.
Assisted in ET intubation under the guidance of Dr.Charan sir
During rounds I have actively involved in ICU and AMC patient's case discussion .
one case in particular gave us a tough challenge, we couldn't control the Patient's fever spikes, we tried in all possible ways to diagnose him but couldn't. , Later after numerous tests He was referred to higher center, i have  followed the case and got to know that the patient have SLE.
All the symptoms patient had was really atypical.
that made me realise that the books we read and the real life cases are quite different and unique and we learn alot from real life cases.

NEXT 15 days i have been posted in PSYCHIATRY
during this time i have seen PANNIC ATTACK, SCHIZOPHRENIA , GENERALSED ANXIETY DISORDER, ALCOHOL DEPENDENCE, BIPOLAR cases.

 learnt how to deal with the different types of patients.
was really proud of our college psychiatry faculty as they made great efforts to reduce the stigma around psychiatry illnesses.

Was able to help PANNIC ATTACK patient by diverting and helping the patient to learn few diversion techniques.

Now this 30 days from 12/11/2022  to 11/12/2022
 i have been posted for Unit duties.


1.During the first week we had one admission in ICU

 DIAGNOSIS: COPD WITH RIGHT HEART FAILURE
with k/c/o DM ,HTN 
? AKI on CKD 
2decho video link.

LEARNING POINTS: 
saw raised jvp in this patient
jvp video link.
Typical barrel shaped chest was seen in this COPD patient.(PICS IN BLOG LINK)




2.During 2nd week 2nd patient in ICU

my co INTERNEE has done this blog and i have continued it from 26/11/2022 


This is a case OF ARTERIAL FIBRILLATION with HEART FAILURE WITH COPD WITH ANEMIA WITH BICYTOPENIA.
LEARNING POINTS: 

• suspecting her very low hemoglobin levels i,e 5 gm/dl could be the cause for her right heart failure.
Anemia could be the result of poor diet 
• Role of anticoagulation therapy in patients with Atrial fibrillation. 
• Learnt about CHA2DS2-VASC score
• Role of Diltiazem in rate controlling, as this patient was having heart rate around 110- 130 bpm(irregular) , after treating her with this drug it came to around 80- 90bpm.


New admission
28/11/2022
C/O 
A 15 YEAR OLD MALE STUDENT WAS BROUGHT TO CASUALTY WITH C/O FEVER SINCE 15 DAYS
(EVENING RISE IN TEMPERATURE) 
ASSOCIATED WITH CHILLS & RIGORS
C/O BLOOD IN URINE SINCE 3 DAYS
C/O 1 EPISODE OF BLACK COLORED STOOLS 3 DAYS BACK
CONSTIPATION SINCE 4 DAYS
Learning points: 
• Learnt how to manage Dengue 



29/11/2022 
During rounds today one patient from ward was brought to icu, 
He had seizures and went into cardiac arrest.

• Intubated this patient under the guidance of Dr.Raveen sir
• Done CPR .
unfortunately He couldn't be revived.
Learnt Intubation steps. And CPR protocol and procedure.


on 1 /12/2022 
we had admission to icu.
This is a case if 17 year old female came to casualty with c/o
INVOLUNTARY MOVEMENTS of B/L 
UL & LL - 1 EPISODE 30 MINS AGO.(NO TONGUE BITE,FROTHING, INVOLUNTARY MICTURITION. POST ICTAL CONFUSION PRESENT)  .

•you can find the Detailed case here -->

LEARNING POINTS:
•I have inserted a RYLES tube &  a FOLEYS Catheter to this patient.

• wittnessed a very peculiar type of tonic seizures,which lasted for about 30 seconds with a 60 seconds gap for 15 to 20 Minutes without regaining of Consciousness. the video is attached in the below link. 

•we have  conservatively managed this patient.
we did EEG while she is having seizures. you can watch the video here --> 

• i have learnt how to manage and stabilize a seizures case.


8/12/2022
collecting venous samples 






INSERTING IV CANNULA





Case: 
this is a CASE OF 55 YR OLD MALE WITH C/C 
 PAIN ABDOMEN SINCE 1 DAY
WITH VOMITINGS (5 EPISODES) 
Diagnosis: Acute on chronic pancreatitis 

Learning points: 
Learnt management of acute pancreatitis.
inserted NG TUBE in this patient 

at

Thursday, 17 November 2022

80 yr old male with B/L pedal edema,sob,fever..

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input
This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome
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 diagnosis and treatment plan. 

This is a case of 80 year old male with shortness of breath ,right side chest pain,facial puffiness since 3 days.

CHIEF COMPLAINTS: 
A 80 year old male patient brought to casualty with 
c/o B/L pedal edema since 1 month
SOB since 3 days
right sided chest pain since 3 days
facial puffiness since 3 days
HISTORY OF PRESENTING ILLNESS:
patient was apparently asymptomatic 3 years back then he developed B/L pedal edema which gradually progressed till knee.
SOB - gradually progressed but subsided on sitting.
sob on lying down 
Chest pain - non radiating
no H/O nausea, vomiting, sweating
 HISTORY OF PAST ILLNESS: k/c/o HTN ,DM from 3 years.
and is on medication for the same.?
TREATMENT HISTORY : In medication for DM - II & HTN.?
PERSONAL HISTORY:
Appetite - normal
Diet - mixed 
Bowels- regular
Micturition - normal
Habbits:
 Alcohol -(Regular ) ?
Beedi - 3- 4 per day (since 40 years)
FAMILY HISTORY: NOT SIGNIFICANT
GENERALL EXAMINATION:
NO PALLOR,ICTERUS, CYANOSIS ,CLUBBING LYMPHADENOPATHY.
OEDEMA OF FEET +
VITALS:
AT THE TIME OF ADMISSION (17/11/22)
TEMP-98.6 F
PR- 52
BP- 150/80 mm of hg
SPO2 - 97%
GRBS - 12⁹ MG/DL 

SYSTEMIC EXAMINATION
CVS:
S1 ,S2 HEARD
JVP - RAISED

NO THRILLS / MURMURS

RESPIRATORY SYSTEM :
 
TRACHEA - CENTRAL
VESICULAR BREATH SOUNDS
BAE + with wheeze in the left infra scapular and infra axillary area
NO ADVENTITIOUS SOUNDS

PER ABDOMEN:
shape - scaphoid
no tenderness
no palpable masses
no organimegaly
bowel sounds +

CNS -  patient is conscious
speech normal
higher mental functions - normal
Motor functions - normal
REFLEXES 
BICEPS - ++
TRICEPS -++
SUPINATOR-++
KNEE-++
ANKLE -++

INVESTIGATIONS: 

18/11/22



ECG 17/11/22  6.25 PM



18/11/22 12.20 pm
2D ECHO

19/11/22
Usg 

Temperature and vitals monitoring chart
Input/ output 
19/11/22

DIAGNOSIS: COPD WITH RIGHT HEART FAILURE
with k/c/o DM ,HTN 
? AKI on CKD





18/11/2022

AMC BED NO 1
S:-
80 years old male B/L pedal edema since 1 month , SOB 3 DAYS, Fever 3 days, Rt sided chest pain since 3days
Admitted on 17-11-2022
K/c/o HTN,DM From 3 years on medication 
O:- 
Patien is conscious, coherent, cooperative 
Bp: 140/80
PR:108 bpm
Temp:98.6
Rr:19
CVS:S1 S2 HEARD
RS: BAE +
P/O: SOFT ,NON TENDER
CNS:NFND


A:-
COPD WITH RIGHT HEART FAILURE (CORPULMONALE)

P:-
1 FLUID RESTRICTION < 1-5 lit I day
2 SALT RESTRICTION < 2gm/DAY
3 T LASIX 40MG BD
4 TAB MONTAIR-LC OD
5 NEBULISTATION WITH DUOLIN &BUDECORT 8th hourly
6 TAB PAN 40 MG PO/0D

19/11/22
AMC BED NO 1
S:-
80 years old male B/L pedal edema since 1 month , SOB 3 DAYS, Fever 3 days, Rt sided chest pain since 3days
Admitted on 17-11-2022
K/c/o HTN,DM From 3 years on medication 
O:- 
Patien is conscious, coherent, cooperative 
Bp: 120/70
PR: 62bpm
Temp: 98.6 F
Rr:16
CVS:S1 S2 HEARD
RS: BAE +
P/O: SOFT ,NON TENDER
CNS:NFND


A:-
COPD WITH RIGHT HEART FAILURE (CORPULMONALE)

P:-
1 FLUID RESTRICTION < 1.5 lit I day
2 SALT RESTRICTION < 2gm/DAY
3 T LASIX 40MG po/ BD
4.T.CINOD 10 MG PO/OD 
5.TAB MONTAIR-LC PO/OD
6.NEBULISTATION WITH DUOLIN & BUDECORT 8th hourly

at
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