Imama Muhmeen : March 2023

65/F with Altered sensorium secondary to hyperthyroidism

[13/3/2023]

A 65 year old female pt presented to Gen surg opd with complaints/of

swelling in front of neck since 2years

C/o pain in swelling since 20 days

Pt was apparently asymptomatic 2 years back then she developed a swelling in neck which is insidious in onset, gradually progressive to present size of 9x6cm. Associated with pain (pricking type),

non radiating,

no aggrevating or relieving factors

H/0 difficulty in swallowing since 6 months.

H/o difficulty in breathing since 6 months

No h/o hoarseness of voice

No other swelling in the neck

No other h/o s/o hypothyroidism

No h/o fever, nausea, vomiting

No h/o loss of appetite or weight loss

No h/o sleep disturbances

Bowel and bladder habits regular.

DIAGNOSIS: SOLITARY THYROID NODULE

ON [19/3/2023]

PT REFERRED TO GEN MED I/V/0 SHORTNESS OF BREATH AND IRRITABILITY SINCE TWO DAYS.

Hopi:

No h/o bone pain, cough, hemoptysis, jaundice, abdomen fullness, headache and seizures.

Past history:

H/o hyperthyroidism since 11years

Surgical history of Right hemithyroidectomy 6 years back

H/o hysterectomy done 40 yrs ago

Not a k c o Hypertension, CAD, TB, asthma, epilepsy.

PSYCHIATRY REFERRAL:

C/O

INCREASED IRRITABILITY

Unability to recognise family members

Abnormal behaviour in the form of moaning and incoherent sounds , trying to get up and leave

Pts sleep decreased, appetite decreased

Self care and hygiene maintained by od.

Not able to do regular daily activities due to physical illness.

Hopi:

No h/o head injury, seizure activity

No h/o blood in vomiting/ stool

No h/o pervasive low moods, easy fatiguability or suicidal ideations

No h/o palpitations, fearfulness or feeling of impending doom

No h/o grandiose or flight if thoughts

No h/o repetitive thoughts or actions

Past history

H/o alcohol consumption since 30 years [initially toddy currently whiskey][consumption amounts accurately not known]

Family History: no significant psychiatric illness in family

MSE: pt sitting on the bed awake and alert but not responding to her name. pt is restrained to the bed (soft restrain) .

Thin built , cannula in place

Enterotoxigenic E. coli (ETEC) + not maintained

Psychomotor agitation increased

Speech - incoherent and decreased

Mood/Affect - agitated and IRRITABILITE

Thought and perception- cnbe

Not oriented to time place and person

* delirium due to general medical condition *

psychiatric Treatment plan

1.Tab pregabalin 75mg

2.tab oxazepam 15mg po/sos

Personal History:

DIET: MIXED

APPETITE: NORMAL

BOWEL AND BLADDER MOVEMENTS: REGULAR

SLEEP: ADEQUATE

ADDICTIONS: NO

Family History:

H/o thyroid swelling malignancy in father.

Treatment history:

CARBIMAZOLE 10mg po/bd

Salbutamol for dyspnea

Menstrual History

Menarche 11 years

Age at marriage 15 years

Age at 1st child born 18years

Menopause at 45 years

General Examination

O/e Pt is c/c/c

Oriented to time place and person

Temp : 97.4

Pr : 84/min

BP: 130 /80 mmhg

Spo2 : 98% on RA

Cvs : s1s2+ no murmurs

RS : bae+ ,nvbs

Moderately built and nourished

Texture of skin - normal

Hair - Normap

Exophthalmos -present

Tremors - present

No signs of pallor,icterus, cyanosis,lymphadenopathy & pedal edema

Local examination

On inspection

A 8x6cm Solitary vertically oval swelling seen on left side of neck.

Extending superiorily above thyroid bone.

Inferiorly beyond the suprastwrnal notch 5cm away from right sternocleidomastoid

Engorged veins present

A transverse scar of 3x1cm present at right side of neck

Skin over swelling NORMAL

smooth surface

Borders are well defined

Swelling moves up&down with deglutation

No visible pulsations

Lower border of swelling visible

Trachea appears to be deviated to right side

No other swellings in neck

No discolouration or erythema

Palpation:

No local rise of temperature

No tenderness

All inspectory findings confirmed

Surface is smooth,

Hard in consistency

Restricted mobility

KOSHERS NEGATIVE -

Carotid pulsations fast on both sides

NO PALPABLE THRILL,

NO PALPABLE CERVICAL LYMPH NODES

Auscultation

No resonant note over manubrium sternum

Percussion

Bruit heard

DIAGNOSIS

Altered sensorium secondary to

?Hyponatremia ?uremia

?Aki on ckd

Solitary thyroid nodule 2° to hyperthyroidism

Hypercalecimia and hyperkalemia secondary to CKD

Heart failure with mid range ejection fraction

Treatment

1.Iv fluids 0.9% NS @ 50ML/hr

2.INJ lasix 20mg iv/od

3. Tab ECOSPRIN 75/10 p0/od

4. Tab nodosis 500mg po/bd

5. TAB CARBIMAZOLE 20mg po/bd

6. Tab propanolol 20mg po/bd

7. Strict I/O monitoring

8. GRBS MONITORING 6TH HOURLY

9. Vitals 4th hrly

10. TAB AMLONG 5mg po/only after informing respective Dr's.

25/4/2023

Amc bed 3

S

No Fever spikes

Stools passed

O

Pt is c/c/c

Oriented to time place and person

Temp : 98.3

Pr : 86/min

BP: 130 /70 mmhg

Spo2 : 98% on RA

RR : 18/min

Cvs : s1s2+ no murmurs

RS : bae+ ,nvbs

Cns : NAD

GCS: E4V5M6

P/A : soft, non tender

A

Altered sensorium secondary to

?Hyponatremia (resolved)

?uremia

?Aki prerenal (resolved)

Solitary thyroid nodule 2° to hyperthyroidism

Hypercalecimia and hyperkalemia secondary to RF

Heart failure with REDUCED ejection fraction (35%)

S/P RT. HEMITHYROIDECTOMY 15YRS BACK WITH HTN

P

1.. Tab ECOSPRIN AV 75/10 p0/od

2. TAB CARBIMAZOLE 20mg po/bd

3. Tab propanolol 20mg po/bd

4. Tab DYTOR 20mg po/bd

5. NODOSIS. 500MG PO/BD

6. OINT. THROMBOPHOBE LA/TID

7. GRBS MONITORING 6TH HOURLY

8. Vitals 4th hrly

88/F with RECURRENT HYPOGLYCEMIA AND ADRENAL INSUFFICIENCY. HYPOVOLEMIC SHOCK 2° TO ACUTE GE(VIRAL TOXIN)

21/3/2023

A 88 yrs old Female presented to casualty with

C/o irrelevant talk and altered mental status since 3 hours.

Loose stools since yesterday (3 episodes)

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic till yesterday and then she developed loose stools,3 episodes watery in consistency, non blood stained non foul smelling. Pt was found unconcious, not responding to verbal commands and in altered sensorium and her speech being non cohorent .

2 D echo was done

2 D echo ( CAD , LAD + territor) , Global Hypokinesia , Severe LV dysfunction

No history of chest pain , palpitations , giddiness.

No h/o weakness in both limbs and now developed hypoglycemia with grbs of 31mg/dl

No h/o involuntary movements in both limbs

No h/o fever, vomiting's, chest pain, sob

PAST HISTORY

K/c/o HEART FAILURE with EJECTION FRACTION 42% secondary to ant wall MI

with PRE RENAL AKI AND RT LOWER LIMB CONSOLIDATION WITH URETHRAL CARUNCLE

N/ K/C/O HTN , DM , CVA , Epilepsy , Asthma

PERSONAL HISTORY:

DIET: MIXED

APPETITE: DECREASED

BOWEL AND BLADDER MOVEMENTS: REGULAR

SLEEP: ADEQUATE

ADDICTIONS: NO

ON EXAMINATION :

PATIENT IS CONSCIOUS NON COHERENT AND COOPERATIVE

GENERAL EXAMINATION:

NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDEMA

VITALS:

BP- 70/40 MMHG

PR- 116BPM

RR- 20CPM

SPO2- 95 @RA ,

GRBS- 31MG/DL

CVS- S1 S2 HEARD. NO MURMURS

RS -Barrel shaped chest , BAE +

Crepts + , Left IAA ,ISA

Bronchial breath sounds ,

Right ISA

PA - soft , nontender

TEMP - AFEBRILE

CNS : Not oriented to Time, place

GAIT - NORMAL

GCS- E4V5M6

Investigations

Hb-7.9

Tlc- 9900

L-19

Pcv-260

Mch- 26.3

MCHC- 30.4

RBC-3.00

PLT-2.65

Na-132

K- 3.6

Cl-96

Ca-1.0

B urea-74

Sr creatinine-2.4

Updated fever chart as of 24/4/23

Treatment

1. INJ 25% DEXTROSE 30ML/HR/IV

2. IV FLUIDS 0.9% NS @ 50ML/HR/IV

3. INJ. CIPROFLOXACIN 500MG IV/BD

4. INJ. METROGYL 500MG IV/TID

5. INJ PAN 40MG IV/OD

6. GRBS HOURLY MONITORING

7. STRICT I/O CHARTING

8. MONITOR VITALS.

23/3/23

ICU BED 4

S

NO FEVER SPIKES

STOOLS NOT PASSED

O

PT IS IRRITABLE

ORIENTED TO TIME PLACE AMD PERSON

Temp : 98.4

Pr : 84/min

BP: 70 /50 mmhg

Spo2 : 96% on RA

RR : 18/min

Cvs : s1s2+ no murmurs

RS : bae+ ,nvbs

Cns : NAD

GCS: E4V5M6

P/A : soft, non tender

A

Recurrent hypoglycemia under evaluation

AkI (?PRERENAL 2° TO DEHYDRATION)

HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GF (?VIRAL TOXIN)

HEART FAILURE WITH MID RANGE EJECTION FRACTION (42%) SECONDARY TO CAD (OLD AWMO)

? ADRENAL INSUFFICIENCY

P

1. Iv fluids NS @70ML/HR

2.INJ CIPROFLOXACIN 500MG IV BD (D2)

3. INJ METROGYL 500MG IV TID (DAY3)

4. TAB ECOSPRIN GLLD 75G PO OD

5.GRBS HOURLY MONITORING

6. STRICT I/O CHARTING

7. MONITOR VITALS 2ND HOURLY

24/4/23

ICU BED 4

S

NO FEVER SPIKES

STOOLS NOT PASSED

O

PT IS IRRITABLE

ORIENTED TO TIME PLACE AMD PERSON

Temp : 96.4

Pr : 74/min

BP: 90 /50 mmhg

Spo2 : 96% on RA

RR : 18/min

Cvs : s1s2+ no murmurs

RS : bae+ ,nvbs

Cns : NAD

GCS: E4V5M6

P/A : soft, non tender

A

Recurrent hypoglycemia under evaluation

AkI (?PRERENAL 2° TO DEHYDRATION)

HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GF (?VIRAL TOXIN)

HEART FAILURE WITH MID RANGE EJECTION FRACTION (42%) SECONDARY TO CAD (OLD AWMO)

? ADRENAL INSUFFICIENCY

P

1. Iv fluids NS @70ML/HR

2.INJ CIPROFLOXACIN 500MG IV BD (D3)

3. INJ METROGYL 500MG IV TID (DAY2)

4. TAB ECOSPRIN GLLD 75G PO OD

5.GRBS HOURLY MONITORING

6. STRICT I/O CHARTING

7. MONITOR VITALS 2ND HOURLY

79 y/o male with Recurrent CVA and left hemiplegia with Aspiration pneumonia and seizures disorder

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

COMPLAINTS AND DURATION:

A 79 y/o male was brought to casuality with c/o cough since 1 & half month ,

fever since 10 days

difficulty in swallowing and h/o Aspiration pneumonia since one month

C/o altered sensorium since 3 days

HOPI

Patient is a known case of cva with left hemiplegia, DM type 2 , Hypertension, Thyroid disorders, and bronchial asthma.

Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing.

H/o cough on intake of liquids.

H/o change of voice since 20 days, insidious, hoarse in character and

SLURRING OF SPEECH +present

No h/o difficulty in breathing, breathlessness, hemoptysis

Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).

H/O WEAKNESS in LEFT upper and lower limb since 4 years aggrevated since 4 days.

N/h/o vomiting, chest pain, loose stools.

PAST HISTORY

Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od. Tab zoryl mv , po/od

History of events:-

• 10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.

• 7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.

K/c/o CVA with left hemiplegia since 7 years.

K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg

K/c/o hypothyroidism since 5 years on thyronorm 25mcg.

• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.

• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.

PERSONAL HISTORY

Appetite lost,

Mixed diet

Bowel- constipated,

Bladder regular

No known allergies and Addictions.

i.e non alcoholic and non smoker

Family History- not any

Treatment history

•Tab TELMA AM 40mg po/od since past 10years

•Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years

• thyronorm 25mcg. Since5 years

GENERAL EXAMINATION

O/e PT IS arousable but not oriented.

Pt not cooperative mostly.

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION

PR-90 BPM

BP- 140/80MM HG

RR- 22 CPM

SPO2- 98% AT RA

GRBS - 183mg/dl

SYSTEMIC EXAMINATION:

Respiratory :-

Inspection :

palpation :

Auscultation :

percussion - BAE +

B/L GRUNTING +

ICA, ISA, SSA

CNS

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E3V3M5

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,

CRANIAL NERVES- cannot be elicited

SENSORY SYSTEM- cannot be elicited

MOTOR SYSTEM:

•TONE- hypotonic

•POWER- cannot be elicited

• B/L REFLEXES:

BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE - hypotonia

PLANTARS- hypotonia

CVS

ASCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

AUSCULTATION: no bowel sounds heard

CLINICAL IMAGES

C/o smth hemiscrotum

O/e

bed sores

C/o asymptomatic lesions all over the body since 2 months

H/o application of unknown topical medications used

O/e multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back

•Diffuse xerosispresent

• single ulcer of size 1.5x1.5 cms (approx) over the back.

Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.

( +? TROPHIC ULCER )

INVESTIGATIONS

MRI BRAIN-

OBSERVATIONS:

• Large area of encephaolomalacia in right occipito -temporo lobes and righ parietal lobes.

• Prominence of sulci and cisterns.

• Bilateral periventricular hyperintensity.

• Rest of the Cerebral parenchyma shows normal gray/white matter differentiation.

• Basal ganglia and Thalami are normal.

• Brain stem normal.

• Cranio-vertebral and Cervico-medullary junctions are normal.

• Sella, pituitary and parasellar regions are normal. Stalk and hypothalamus are normal. Posterior pituitary bright spot is normal.

• No evidence of abnormal calcifications, vascular anomalies on SWI sequences.

IMPRESSION:

• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.

• Diffuse cerebral atrophy. Chronic small vessel ischemia.

Note: Poor quality of images due to motion artefacts

CUE :-

AFB-TRACE

PUS CELLS -2-4

EPITHELIAL CELLS -2-3

Usg abdomen -

1) b/l mild hilar prominence - likely pulmonary artery Hypertension.

(Co relatewith 2D echo)

2D ECHO

CBP.

RFT

LFT

DIAGNOSIS

Recurrent CVA with Hypertension, T2 DM, Thyroid disorder, BRONCHIAL ASTHMA, and seizures disorder.

TREATMENT

1) TAB ECOSPRIN 150 mg RT/OD

2) TAB CLOPIDOGREL 75 MG RT/OD

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS ,

MUCUMZY 8th hourly

5) CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

50 ML Milk 2nd HRLY.

7) INJ HAP SC | TID / premeal a/l to GRBS

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL TOOMG RT/OD

67 year old female pt with cervical and lumbar spondylitis

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

COMPLAINTS AND DURATION:

A 67 y/o female presented with c/o tingling, numbness and weakness in both hands since 20 days.

C/o sob since 1 month

H/o fever 1 week back

Neck pain( radiating type), lower back aches (radially to lower limbs) and pain in b/l upper and lower limb since 6 months

Blood in stools since 1 year?

Burning micturition since 3 months (on and off)

History of Presenting Illness:

Pt was apparently asymptomatic 6 years back when she developed tremors in both hands. Insidious in onset and gradually progressive in severity. Not affecting day to day activities.

-2 years back pt had continous white discharge for 1 month for which she was evaluated and diagnosed with carcinoma cervix and received chemotherapy and radiotherapy for 1 month.

- since 1 year back pt has developed passage of blood in stools (dark to bright red in color) frank blood present

• upper gastric endoscopy and colonoscopy were done and showed radiation proctitis.

PAST HISTORY:

N/h/o loose stools or vomitings

H/o occasional fever (low grade) associated with chills relieves on medication, no diurnal variations

N/h/o cough,

Pt is a k/c/o b/l osteoarthritis knee for which she takes medications I.e nsaids intermittently

N/k/c/o - htn, dm, asthma, Thyroid disorders, epilepsy,

PERSONAL HISTORY:

Normal appetite,

Vegetarian diet with regular bowel and bladder habits

No known allergies

Addictions - toddy once a month

Non smoker, no other drug use

FAMILY HISTORY:

TREATMENT HISTORY:

MENSTRUAL HISTORY:

OBSTETRIC HISTORY :

GENERAL EXAMINATION:

O/e PT IS C/C/C

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION:

PR-98 BPM

BP- 110/70MM HG

RR- 18 CPM

SPO2- 99% AT RA

GRBS - 103mg/dl

SYSTEMIC EXAMINATION:

CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

PER ABDOMEN:

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT