Internship assessment

This blog is made based on my experience that showcases my competency and pitfalls

UNIT duties— 1st one month ie

                          (4/3/23-4/4/23)

>I would check the vitals of my patients and update SOAP notes Daily morning   

>Have taken samples and took the patients for required investigations (CECT,USG ABDOMEN,XRAYS AND ONCE GOT IVP DONE FOR A URETHRAL STRICTURE CASE)          

>have done ascitic tap on a patient 

On OP DAY

>I have checked vitals of every patient 

>Examined for reflexes, postural hypotension, Romberg’s sign

>Have learnt basic management protocol for sob, chest pain and headaches 

ICU AND AMC DUTIES

>My first and foremost important work in ICU AND AMC was to monitor the vitals of patients timely ( varying from hourly basis to 2nd hourly)

>Have learnt how to take ABGs and many other samples for lab investigations.

>Have Learnt how to manage in critical situations 

>I have Assisted in intubation for 1 patient

>Assisted Ryles insertion for patients  

>Assisted in Foleys been put for patients

>Have given RT feeds 

  

NEPHRO DUTIES:-

>monitored patients who came for dialysis 

>Handled Day care patients who came for dialysis. 

> Learnt about dialysis machine , central line care and fistula importance

>Have given NTG to 1 patient and have monitored the patient meticulously 

> Have learnt how to maintain patients BP and GRBS while dialysis is going on

> Have Learnt about drugs used in hypo and hypertension.

WARD DUTIES:-

> Have updated soap notes of patients

>Helped my co interns in updating soap notes 

>Have taken samples

>was present for rounds and presented the cases 

>with the help of my Co intern , i have completed all the works assigned 

PSYCHIATRY DUTIES:-

>Learned about importance of history taking 

>vitals monitoring done for OP patients

Examples like :

1. Schizophrenia 

2.OCD

3.ALCOHOL DEPENDENCE SYNDROME 

4. TOBBACO DEPENDENCE SYNDROME 

> learnt about the medications given to the patients and their side effects

> have seen and learnt from pgs regarding how they handle patients in DAC

>Have had a catatonic schizophrenic patient admitted, for whom I have monitored and learned how BENZODIAZEPINES worked in this patient.

75F recent ALTERED SENSORIUM right hemiparesis

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 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.

75/F presented to casuality in drowsy state at 7:45pm.

History of presenting illness  

Patient was apparently asymptomatic till afternoon after which patient had sudden loss of consciousness followed by fall after which patient became altered and was not coherent and confused. BP after the fall was around 170/110. No history of seizure activity.

No H/o frothing, up rolling of eye balls, involuntary micturition and defecation. No H/o ENT bleed, projectile vomitings. 

Past history 

N/k/c/o DM, HTN, asthma, epilepsy, TB, thyroid disorders.

On examination 

Patient is drowsy but arousal.

GCS:E3V4M6

BP:110/80mmhg.

PR:92/min

RR:18CPM

SPO2:98%ON ROOM AIR 

TEMP: 98°F

CVS:S1,S2 HEARD,NO MURMURS. 

RS:BAE+,NVBS.

PA:SOFT AND NONTENDER 

CNS:PUPILS :NORMAL SIZE AND NON REACTIVE. 

TONE: RT. LT

        UL HYPOTONIA NORMAL

    

  LL HYPOTONIA NORMAL

POWER:

        UL 0/5. 4/5   

        LL 0/5. 4/5

REFLEXES:

        B: 2+ 2+

        T: 2+ 2+

        S: 2+ 2+

        K: 3+ 2+

        A: 1+ 2+

        P: EXT. FLEXOR

PROVISIONAL DIAGNOSIS 

ALTERED SENSORIUM (RESOLVED) 2°TO ?ACUTE HEMORRHAGIC STROKE (SUBACUTE HEMATOMA IN LEFT PARIED OCCIPITAL REGEION).

On 02/05/2023

S:

4 FEVER SPIKES SINCE YESTERDAY MORNING

STOOLS PASSED 

O:

ON EXAMINATION:

Patient is conscious but not oriented. 

Gcs:E4V5M6

BP:140/90mmhg.

PR:98BPM

RR:18CPM

TEMP:96.7°F

CVS:S1,S2 HEARD ,NO MURMURS. 

RS:BAE+,NVBS.

CNS:PUPILS:B/L NORMAL SIZE REACTING TO LIGHT.

TONE: RT. LT

   UL: HYPOTONIA NORMAL

    

  LL:. HYPOTONIA NORMAL

POWER:

   UL. 0/5. 3/5   

    LL. 0/5. 3/5

REFLEXES:

        B: 2+ 2+

        T: 2+ 2+

        S: 2+ 2+

        K: 3+ 2+

        A: 1+ 1+

        P: EXT. FLEXOR

A:

ALTERED SENSORIUM (RESOLVED) 2°TO ?ACUTE HEMORRHAGIC STROKE (SUBACUTE HEMATOMA IN LEFT PARIED OCCIPITAL REGEION).

P:

RYLES FEED :100ML WATER EVERY 2ND HOURLY 

200ML MILK EVERY 4TH HOURLY. 

INJ. MANNITOL 100ML IV/ TID 

MONITORING VITALS HOURLY

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

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,

MOTOR SYSTEM:

  TONE- NORMAL, 

  POWER- 5/5 IN ALL LIMBS REFLEXES: 

  B/L REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+

  PLANTARS- B/L FLEXORS.

INVESTIGATIONS :

ECG

DIAGNOSIS:

• ?Cervical and lumbar spondylosis  

• Carcinoma cervix -s/p CTx & RTx with radiation

• sigmoid  proctitis

• essential tremors

• mid ejection heart failure with anemia 

TREATMENT:

1. Monitor vitals

2. Tab. Ultracet 1/2 tab po/qid

3. Tab. Dolo 640mg po/sos

4. High fibre diet

5. Syp. CREMAFFIN 10ml po/ in 1glass water

6. OINTMENT SMUTH for L/A before and after defecation

 7. Sitz bath with betaine three tines a day.            for 10 mins

A 75 YEARS OLD MALE WITH ALTERED SENSORIUM

MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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'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 comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE 

A 75 year old male came with complaints of 

 fever since 10 days 

altered sensorium since 5 days  

HOPI:

Patient was apparently asymptomatic 10 days back and then developed fever which was high grade not associated with chills and rigor. Then he developed altered sensorium since 5 days he was not able to recognise his family members.

PAST HISTORY:

Not a K/C/O DM, HTN, TB,EPILEPSY, ASTHMA

Has hypo-pigmented patches on b/l lower limbs and b/l nipples since 6 years using herbal medication regularly, itching is present.

PERSONAL HISTORY:

He is Married

He consumes 

Mixed diet 

sleep is adequate 

Appetite normal

bowel and bladder movements are regular

He Consumes Alcohol twice a week (90ml) since 50 years presently abstinent since 15 days 

He smokes beedi 1-2 packs/day since 55 years 

FAMILY HISTORY: no similar complaints in the family.

DAILY ROUTINE: Wakes up early in the morning around 5:00am and then goes to the farm, comes back home at 10:00am has breakfast (Tea and bread or some tiffin), from 10:00am to 6:00pm he stays home takes rest and does house chores. Takes his meals on time (3 meals/day).

Sleeps at 10:00pm and the routine continues.

CLINICAL IMAGES:

GENERAL EXAMINATION:

Patient is conscious ,non-cooperative, not oriented to time, place and person.

Thinly built and nourished.

VITALS:

BP: 120/70mmhg

PR: 90bpm

RR: 20cpm

Temp: 100f

SYSTEMIC EXAMINATION:

RS:

Inspection : barrel shape 

Decreased breath sounds on right side 

Diffuse expiratory wheeze

CVS: s1,s2 no added sounds

P/A: not tender

Pt is altered

GCS - E3V1M6 

Speech - making incomprensible sounds 

Pupils:NSRL

Motor 

Power : Not moving his left upper limb and lower limb as actively as right side

Tone : Normal

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - - - - - Flexion 

Neck rigidity : Present 

Kerning's : Positive 

Brudzski : Negative

PROVISIONAL DIAGNOSIS: ALTERED SENSORIUM UNDER EVALUATION 

INVESTIGATIONS:

On Day1 

ABG: Day 1 at 10:43pm

ABG: Day 1 at 11:51pm

3/09/22

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.INJ.IVF DNS 50ml/hr

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.MONITOR VITALS EVERY 6th hrly

7.GRBS MONITORING EVERY 4th 

Day 2

S: fever since 10 days and altered sensorium since 5 days

Presently altered sensorium 

O: pt is conscious,uncooperative,not oriented to time,place and person.

BP: 120/70mmhg

PR: 90bpm

RR: 20cpm

Temp: 98.6f

SYSTEMIC EXAMINATION:

RS:

Inspection : barrel shape 

Decreased breath sounds on right side 

Diffuse expiratory wheeze

CVS: s1,s2 no added sounds

P/A: not tender

CNS:

Pt is altered

GCS - E3V1M6 

Speech - making incomprensible sounds 

Motor 

Power : Not moving his left upper limb and lower limb as actively as right side

Tone : Normal

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - - - - - Flexion 

Neck rigidity : Present 

Kerning's : Positive 

Brudzski : Negative

A: ?Altered sensorium under evaluation

?Alcohol withdrawal syndrome 

P:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.INJ.IVF DNS 50ml/hr

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.MONITOR VITALS EVERY 6th hrly

7.GRBS MONITORING EVERY 4th hrly

INVESTIGATIONS:

ABG: Day 2 at 6:17 am

ABG: Day 2 at 4:46pm

Plan: Patient intubated on ACMV VC MODE as he was hypoxic Post Intubation Ventilator Settings : 

RR - 16

Fio2 - 40

PEEP - 5 

TV - 400

Post Intubation Vitals :

Pupils - B/L Fixed Pin point Pupils 

BP - 100/70mmHg 

PR - 116/Min 

RR - 22/Min 

Spo2 - 100%

Midaz Infusio - 5ml/hr

Atracurium Infusion - 10ml/hr

ABG:Day 2 at 9:50pm

Day 3

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 29

RR:20

Fio2:30%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 110/70mmhg

PR: 82bpm

RR: 16cpm

Temp: 98.5f

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

8.Inj.MIDAZ 5ml/hr

9.Tab. Azithromycin 500mg PO/OD

Day 3 At 9:30 am 

Pt was able to breath on its own so the changes were done to SIMV -VC Mode 

RR Total - 29

RR - 16

Fio2 - 30 

PEEP - 5 

VT - 400

Vitals - 

BP - 100/80

RR - 38/min

HR - 108/min

Spo2 - 97

ABG: Day 3 at 12:20pm

ABG: Day 3 at 9:20pm

On Day 4

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 29

RR:20

Fio2:30%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 110/70mmhg

PR: 97bpm

RR: 16cpm

Temp: 97.6f

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

Abg day 4 at 9am

CULTURE REPORT:

Abg day 4 at 10:36pm

Abg day 5 at 6:30 am

Day 5

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 34

RR:16

Fio2:21%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 130/70mmhg

PR: 122bpm

RR: 20cpm

Temp: 100.8f

SpO2: 97%

GRBS: 327 mg/dl

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

CNS:

Doll’s eye reflex +

Pt is unresponsive

GCS - E1VTM1

Pupils:B/L equal constricted and reacting to light.

                          R L

Corneal + +

Conjunctival. +. +

Tone : Hypotonia

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - + - - - Flexion

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.Dexamethasone 4mg BD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

8.INJ.Clexane 40mg S/C OD

9.Tab. Azithromycin 500mg PO/OD

10.NEB BUDECORT 12th hrly DUOLINE 8th hourly 

11.Monitor vitals

Abg day 5 at 3pm

Day 6

S:pt removed from ventilation and was put on T. Piece since today morning 7.30 am 

O:

Pt conscious 

GCS:E4VTM4

spontaneous eye opening + 

Spontaneous breathing +

VITALS:

BP: 120/70mmhg

PR: 137bpm

RR: 30cpm

Temp: 101.3f

SpO2: 98%

GRBS: 197 mg/dl at 8:00am

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender,Soft

A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

Plan to extubate

Abg day 6 at 6:30am

Abg day 6 at 9:30am

Abg trends