A 55 year old male patient with pain abdomen since 2 days

General medicine  E - LOG Book 

Final practical examination :  Long case 

- June 08 , 2022

R .Lalu prashanth 

Hall ticket no : 1701006144 

This is an online E-log book to discuss our patient de-identified health

 data shared after taking his/ her guardians sign 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 clinical problem with collective current best

 evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the

 topic of " Patient clinical data analysis" to develop my competancy in

 reading and comprehending clinical data including history, clinical

 finding, investigations and come up with a  diagnosis and treatment

 plan.

LONG CASE

A 46 year old male came to casuality with chief complaints of :

-burning micturition since 10days

-vomiting since 2days (3-4 episodes)

-giddiness since 1day

History of presenting illness:

Patient was apparently asymptomatic 10 days back then he developed

 burning micturition, vomiting since 2 days containing food particles,

 non bilious,non foul smelling(3-4 episodes),later he complained

 of giddiness  for which he was brought to our hospital and

 his GRBS was recorded high value for which he was given NPH 10U

 and HAI 10U.

No history of fever/cough/cold 

No significant history of UTIs

Past history:

10years back patient complained of polyuria for which he was

 diagnosed with Type 2 Diabetes Mellitus, he was started on oral

 hypoglycemic agents(OHA) 10years back

3years back OHAs were converted into Insulin

3years back he underwent cataract surgery

1year back he had injury to his right leg, which gradually progressed to

 non healing ulcer extending upto below knee and ended with

 undergoing below knee amputation due to developement of wet

 gangrene.

Delayed wound healing was present- it took 2months to heal

Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid

Not on any medication

No history of blood transfusion 

Personal history:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol-

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90ml

 whiskey consumed almost daily.Also 1 month on & off  consumption

 pattern previously present 

Family history:

Not significant

General Examination:

Patient is conscious,coherent,cooperative well oriented to place,time,person.

Vitals @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 99F

SpO2: 98% 

GRBS: 124 mg/dl

Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No dehydration

                                 

                              

Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

Investigations:

On admission (19.5.22 )

                

                  

X ray KUB

             

CT scan 

                    

Liver function tests 

              

Renal function tests 

Ultrasound report and abdomen 

                     

LDH - 192

24 hr urinary protein - 434 

24hr urinary creatinine - 0.5 

Culture report : klebsiella pneumonia positive 

                    

Pus cells

21.5.22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.2.22

                

25 .5 .22           

27 .5 .22 

Hb - 7 

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

Provisional Diagnosis: 

Right emphysematous pyelonephiritis and left acute pyelonephiritis and

 encephalopathy secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years

Treatment:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

Day 11:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000