26 year old female with Lower Back pain and Fever

 This is an online E log book to 

discuss our patient's 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.

Chenna Bhavana,

Roll No - 20,

Hall Ticket No - 1701006028.

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 26 year old female cam to the Hospital with :

Chief Complaints :

* Lower Back pain since 15 days 

* Fever since 10 days

History of Present Illness :

* Patient was apparently asymptomatic 15days back then she developed lower back pain which is : 

         ▪️  Insidious in onset 

       ▪️Gradually progressive 

       ▪️ Continuous, Non - Radiating and                               Dragging type of Pain

       ▪️ Diurnal Variation - More during night 

       ▪️ Relieving Factors - Relieved on                                                                     Medication.

* She also developed Fever 10 days Back which is :    

       ▪️  Insidious in onset  

     ▪️High grade 

       ▪️ Assosciated with chills and rigors 

 * Vomiting :

         ▪️Day 1 of admission : 1 episode of                                                                      vomiting 

         ▪️Day 2 : 6 Episodes of Vomiting

         ▪️Color - Yellow

         ▪️Content - Food

         ▪️Not projectile 

         ▪️Relieved on Medication 

* She also complaints of Red colored urine

( Blood in urine ) on the day before admission 

and the day one of admission which is :

      ▪️ Associated with Feeling of Sensation of                  Incomplete Voiding   

      ▪️ Not assosciated with pain or burning                      micturition or difficulty in passing urine

* She complained of Facial puffiness and 

abdominal distension on day 5 of admission 

and which subsided later on.

* No history of Chest Pain, Difficulty in Breathing, Cough, Indigestion or Heart burn .

History of Past Illness : 

* At the age of 10years,  She was diagnosed with Rheumatic heart disease and she underwent a surgery for it  ( Coronary Artery Bypass Graft  and Mitral valve replacement ) following which she took Medication for 2 years and she stopped using them thereafter, and again she started using the medication from the past 7months.

* Not a Known Case of Diabetes Mellitus, Tuberculosis, Hypertension, Epilepsy, Asthma.

Personal History : 

Diet -  Mixed

Appetite -  Normal

Sleep -  Disturbed due to Pain

Bowel and Bladder Movements -  Regular

Addictions - Absent

Family History :

Not Significant

Menstrual History :

* Age at Menarche - 13 Years

* Menstrual Cycle - 28/5, Regular, Moderate flow with Clots.

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 moderately nourished.

Pallor -  Present

Icterus - Absent

Clubbing -  Absent

Cyanosis -  Absent

Lymphadenopathy -  Absent

Edema -  Absent

B. Vitals :

Temperature -  Afebrile

Pulse Rate -   70 BPM

Blood Pressure -   120/70 mmHg

Respiratory Rate -  34/Min

C. Systemic Examination

Per-abdomen examination 

Inspection:

* Shape of abdomen  -   normal

* Movements  -  all quadrants are moving equally with respiration 

* C-section scar is present 

* No engorged veins ,sinuses,swellings

* Striae gravidarum present 

* No visible gastric peristalsis

Palpation :

* No local rise of temperature ,no tenderness

* No palpable mass

* No hepatomegaly ,spleenomegaly

* Kidney ballotable 

Percussion :

* resonant note heard 

Auscultation : 

* bowel sounds heard

Cardiovascular system Examination :

Inspection:

* Midline scar is present 

* Shape of chest normal 

* No precordial bulge 

* JVP not raised 

* No visible pulsations

Palpation: 

* Apex beat felt at 5th ICS 2.5 cm lateral to mid clavicular line

Auscultation :

* S1S2 heard 

* no murmurs 

* Click sound is heard without stethoscope (replaced mitral valve )

Investigations :

On Day1:

Hb:9.8 %

TLC:21,900

N:83,L:7,B:2,M:8

Platelet:2.1 lakh 

Normocytic normochromic anemia

RFT:

APTT :51seconds

PT:25 sec 

INR:1.8

RBS:101 mg/dL

Urea:26

Sr.creatinine :1.4

Na+:141 mEq

K+:3.4

Cl_:106

On day 4

Hb:10.1

Urea :18 

USG :

(Done On the day of admission)

Impression:  Altered echo texture and increased size of right kidney

Provisional Diagnosis : 

Acute Pyelonephritis

Treatment :

IV fluid -NS,RL :75mL/hr

Inj.piptaz 2.25 gm IV TID

Inj.pan 4mg IV OD

Inj. Zofer 4mg IV SOS

Inj.neomol 1gm IV SOS (if temp >101F)

Tab.PCM 500mg /PO/QID

Tab .niftaz 100mg /PO / BD (stopped)

40 year old Male with Shortness of Breath and Chest Pain

 This is an online E log book to 

discuss our patient's 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.

Chenna Bhavana,

Roll No - 20,

Hall Ticket No - 1701006028.

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   40   Year   old   Male   Patient   Came   to  the  Hospital  with  :

Chief Complaints :

* Shortness of Breath since 6 days 

History of Present Illness :

* Patient was apparently asymptomatic 6 days back and then he developed Shortness of Breath which is : 

           ▪️ Insidious in Onset

           ▪️ Gradually Progressive from Grade 1 to                     Grade 2

           ▪️ Aggravated on Exertion and Lying                           down

           ▪️Relieved on Rest and Sitting Position

* Shortness of Breath is associated with :

           ▪️Chest Pain which is Non radiating in                      Nature

           ▪️Loss of Weight about 5 kgs in the last                      month

           ▪️Loss of Appetite

* Shortness of Breath is not associated with :

           ▪️Chest Tightness

           ▪️Wheeze

           ▪️ Palpitations

           ▪️ Cough

           ▪️Hemoptysis

History of Past Illness :

* No History of Similar Complaints in the Past.

* He is Known Case of Diabetes Mellitus since 3 years.

* Not a Known Case of Hypertension, Asthma, Epilepsy, Coronary Artery Disease.

Treatment History :

* He is on Medication since 3 years for Diabetes

         ▪️Metformin 500 mg

         ▪️Glimiperide 1 mg

Personal History : 

Diet -  Mixed

Appetite -  Decreased

Sleep -  Adequate

Bowel and Bladder Movements -  Regular

 Addictions - 

▪️ Alcohol consumption 90ml per day.

▪️Smoking since 20 years, 3 Cigarettes  per day but stopped 2 years back.

Family History :

Not significant

Physical Examination :

A. General Examination 

* Patient is conscious, coherent and co-operative and sitting comfortably on the bed.

* He is well oriented to time, place and person.

* He is mildly nourished.

Pallor -  Absent

Icterus - Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy - Absent

Edema - Absent

B. Vitals 

Temperature -  Afebrile

Pulse Rate -  112 BPM

Blood Pressure -  110 / 70 mm Hg

Respiratory Rate -  45 CPM

SPO2 -  94% at Room Air 

Random Blood Sugar -  201 mg/dl

C. Systemic Examination

Respiratory Examination :

Inspection:

1. Shape of Chest - Asymmetrical

2. Trachea position - Centrally Positioned

3. Apical Impulse - Not seen

4. Movements of the chest: 

       ▪️Respiratory rate - 45 CPM

       ▪️Type / Rhythm - Regular

       ▪️Any accessory muscles involved - Neck muscles are Involved         

       ▪️Intercostal Indrawing - Not Present

5. Skin over the chest ( Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, intercostal swellings ) -  Normal

6. All the areas are normal.

7..Expansion of chest. 

          ▪️  Right - Normal

         ▪️Left - Decreased

Palpation:

1. Temperature and tenderness - No Local rise of Temperature and Tenderness.

2. All inspector findings confirmed.

   ▪️ TRACHEAL POSITION -   Right sided                                                      Deviation of Trachea.

3. Expansion of the chest.

4. Dimensions: 

           ▪️Transverse - 28 cm

           ▪️Anterioposterior  - 24 cm

           ▪️ Circumference  -  82 cm

           ▪️HemiThorax -   RIGHT : 40 cm

                                              LEFT : 42 cm

5. Spinoscapular Distance - Increased on Left side.

6. Tactile vocal fremitus - Decreased on Left InfraScapular  area.

Percussion:

* Dull note is present in the  ISA, InfraSA, IAA. 

Auscultation:

1. Normal breath sounds:  

          ▪️On Right Side - Normal 

          ▪️On Left Side - Absence of Breath sounds                                            in Left InfraScapular area.            

                     -  Decreased Intensity of Breath                                     sounds in Left Suprascapular and                             Infraxillary area      

          ▪️ Type of Breath sounds - Vesicular                                                                Breath sounds                       

          ▪️ Bilateral air entry Present.

2. Any abnormal sounds - Not heard.

3. Any adventitious sounds - Not heard.

Cardiovascular system Examination :

* S1,S2 heart sounds Heard.

* No murmurs.

* JVP - Normal

* Apex beat - Normal

Per Abdomen Examination :

* Soft and Non-tender.

* Bowel sounds heard

* No Guarding / Rigidity

Central Nervous System Examination :

* No focal neurological deficits

* Gait - Normal

* Reflexes - Normal

Investigations :

  *  Fasting Blood Sugar  -  213mg/dl

 *  HbA1c  -  7.0%

  *  Complete Blood Picture :

          ▪️ Haemoglobin  -  13.3 gm/dl

          ▪️Total Leucocyte Count  -  5,600 cells/mm3

          ▪️ Platelets  -  3.57 Lakhs/mm3

                ▪️ Neutrophil Count  -  93%

                ▪️ Eosinophil Count  -  09%

                ▪️ Lymphocyte Count  -  05%

                ▪️ Monocyte Count  -   01%

 *  Serum Electrolytes :

        ▪️ Serum Na  -  135 mEq/L

        ▪️ Serum K  -  4.4 mEq/L

        ▪️ Serum Cl  -  97 mEq/L

 *  Serum Creatinine  -  0.8 mg/dl

 *  Blood Urea  -  21 mg/dl

 *  Liver Function Test : 

              ▪️ Total Bilirubin  -  2.44 mg/dl

                      ▪️ Direct Bilirubin  -  0.74 mg/dl

                      ▪️SGOT (AST )  -  24 IU/L

                      ▪️SGPT ( ALT )  -  09 IU/L

                      ▪️ Alkaline Phosphatase  -  167 IU/L

                      ▪️ Albumin  -  3.29 gm/dl

 *  Pleural Fluid : 

                      ▪️ Sugar  -  96 mg/dl

                      ▪️ Protein  -  5.3 gm/dl

                      ▪️ LDH  -  740 IU/L

                      ▪️ Total Cell count  -  2200 cells/mm3

                      ▪️ Lymphocytes  -  90 %

                      ▪️ Neutrophils  -  10 %

ACCORDING TO LIGHTS CRITERIA: (To know if the fluid is transudative or exudative)

NORMAL:

Serum Protein ratio: >0.5

Serum LDH ratio: >0.6

LDH>2/3 upper limit of normal serum LDH

Proteins >30gm/L

My Patient:

Serum protein ratio:0.7

Serum LDH: 2.3

INTERPRETATION: As 2 values are greater than the normal we consider as an EXUDATIVE EFFUSION.

(confirmation after pleural fluid c/s analysis)

Provisional Diagnosis : 

Left sided Pleural Effusion.

Treatment :

Advice : 

* High Protein diet

* 2 egg whites/day

Medication :

* O2 inhalation with nasal prongs at 2-4 

litres/min to maintain SPO2 >94%

* Injection. Augmentin 1.2gm/IV/TID

* Injection. Pan 40mg/IV/OD

* Tablet. Paracetamol 650mg/IV/OD

* Syrup. Ascoril 2 TSP/TID

* Diabetes Mellitus medication taken regularly

* Monitor vitals 

* GRBS done