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
evidence based inputs.
This E log also represents my patient centered
online learning portfolio and valuable inputs on
Comment box is welcome.
Bhavana Chenna,
Roll No - 20
Case Discussion :
I have been given this case to solve in an order to 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 a Diagnosis and Treatment plan.
A 45 year old Female patient, came to Hospital with :
Chief Complaints :
* Fever since 3 days
* Pain abdomen since 2 days
* Decreased Urine Output since 2 days
* Abdominal distension since morning
History of present illness :
* Patient was apparently asymptomatic 3 days back and came to the OPD with the complaints of Fever since 3 days which is of High grade , Continuous and is associated with chills and rigors.
* Pain abdomen since 2 days in Epigastric region, Right and Left Hypochondrial region,which is sudden in onset and gradually progressive and is of Dragging/Throbbing type.
Not associated with Loose stools, Nausea, Vomiting, Chest pain, Palpitations, Sweating and Giddiness.
* She developed Decreased Urine Output since 2 days which is associated with Acute Retention of Urine since 11pm today, and Bilateral Pedal Oedema upto the shin of tibia which is of Pitting type and not associated with Facial puffiness, Burning Micturition.
* She developed Abdominal distension since morning which is sudden in onset, Gradually progressive.
* She passed stools yesterday and not passing stools and flatus since today morning.
History of Past illness :
* She had deformity in spine i.e., KYPHOSCOLIOSIS since 20 years.
* She had a fracture of Right Femur 5 years back for which she was operated.
* She is not a known case of Hypertension, Diabetes mellitus, Tuberculosis, Epilepsy, Stroke, Coronary artery disease.
Treatment History :
* She used drugs for 5 months prescribed by the Osmania Hospital for Spine deformity.
* She was operated by using Intramedullary Nails for fracture of Right Femur.
* She had a history of NSAID abuse 2/day since 4 years which she stopped using since 2 months.
Personal History :
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowels: Irregular
Bladder movements: Decreased Urine output since 3 days
Addictions: Occasional Toddy drinker.
Family History :
No significant Family history.
Menstrual History :
Age of Menarche: 12 years
Menstrual cycle: 30/5
Obstetric History :
Age at Marriage : 9years
Age at First child birth : 14 years
Gravida : 4
Para : 4
Still birth : 0
Number of living children : 4
Birth History :
Full term Normal delivery.
No history of Birth asphyxia.
Physical Examination :
A. General Examination :
* Patient is conscious, coherent and co-operative and sitting comfortably on the bed.
* She is well oriented to time, place and person.
* She is mildly nourished.
Pallor: Present ++
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Bilateral edema upto the shin of tibia which is of pitting type.
Vitals :
Temperature: Febrile
Pulse rate: 138 Beats per minute which is regular and Normal in volume.
Respiratory rate: 20 cycles per minute
Blood pressure: 130/80 mm of Hg
SPO2: 96%
Random Blood sugar: 140 mg/dl
B. Systemic Examination
Abdomen:
Inspection :
* Shape of Abdomen is Distended.
* Umbilicus is Everted.
* No visible pulsations.
Palpation and Percussion :
* Tenderness is present in Epigastric, Right and Left Hypochondrium.
* Guarding is Present
* Palpable masses are not found.
* Liver and Spleen are not palpable.
Auscultation :
* Bowel sound - Absent.
Cardiovascular system:
* S1 and S2 heart sounds are normal.
* No Murmurs.
Respiratory system:
* Dyspnoea is present.
* Position of Trachea is shifted to Right side.
* Normal vesicular Breath sounds.
* Bilateral inspiratory crepts are present.
Investigations :
Complete Blood Picture:
Haemoglobin :- 9.8 gm/dl
Total Leucocyte count :- 15,500/cumm
Neutrophils :- 93%
Lymphocytes :- 3%
Eosinophils :- 2%
Monocytes :- 3%
Basophils :- 0%
PCV :- 28.6 vol%
MCV :- 85.5 fL
MCH :- 29.3 pg
MCHC :- 34.3 g/dl
Platelet count :- 2.65 Lakhs/cumm
Smear :- Normocytic Normochromic Blood Picture with with Anaemia, Leucocytosis, Neutrophilia and Lymphocytopenia.
Liver Function test:
Elevated Alkaline phosphatase
Increase in Bilirubin levels
Hypoproteinemia ( Decrease in total proteins )
Hypoalbuminemia (Decrease in Albumin )
Renal Function test:
Elevated levels of Urea
Elevated Creatinine
Elevated levels of Uric acid
Complete urine Examination:
Arterial blood gases:
Chest x - ray:
Right Upper lobe Pathology ? FIBROSIS
Abdominal x - ray:
No Significant findings.
Ultrasound (USG):
Impression :
* Hepatomegaly
* Dumbell shaped organized thick collection in
Right Subdiaphragmatic space with Loss of
interface with superior surface of left lobe of
Liver.
Differential Diagnosis :
* Ruptured Liver Abscess.
* Organized collection secondary to Hollow viscous Perforation.
* Organized Intraperitoneal Hematoma.
* Free fluid with internal echoes in Bilateral
Subdiaphragmatic space.
* Grade 3 RPD of right Kidney.
(Left kidney couldn't be evaluated due to Excess bowel gas and kyphosis).
Treatment :
* IVF Normal saline 100ml/hour
* IVF Ringer lactate 100ml/hour
* IVF Dextrose normal saline 100ml/hour
* Injection. METROGYL 750mg IV/TID
* Injection. PANTOP 40mg IV/OD
* Injection. AUGMENTIN 1.2gm IV/TID
* SYP LACTULOSE 15ml PO/HS
* Injection. BUSCOPAN 2ml IV/SOS
* Injection. LASIX 40mg IV/BD
(If BP ≥ 110/70 mm of Hg)
* Temperature, Blood pressure, Pulse rate to be monitored every 4th hourly.
Patient was referred to General Surgery Department for further evaluation.
* On ultrasound Aspiration, it turned out to be Haemorrhagic.
* So they planned for EMERGENCY LAPAROTOMY.
* As the patient's attendant want to get her operated near their home town, she was taken to Hyderabad on the very same day and was Operated there.
* On the next day of surgery, Patient had severe Cough and Shortness of Breath eventually resulting in Abnormal Vital signs.
* On the same day, Patient Expired there in the Hospital.
No comments:
Post a Comment