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
Chandana racha
1801006137
Presentation
https://youtu.be/QsYhokW3L2g
https://youtu.be/HWKa0PSta7U
A 20 yr old girl came to casualty with chief complaints of
Pedal edema since 15 days
Hyperpigmented macules since 15days
Fever since 15 days
cough(dry)since 7 days
decreased appetite since 7 days
shortness of breath since 5 days
decreased urine output since 3 days
Abdominal distension since 1 day
lost ability to speak since 1 day
HOPI:-
Patient was apparently asymptomatic 15 days back then she developed bilateral pedal edema extending till knees which was insidious in onset, gradually progressive no aggravating and relieving factors , for which she took some medication for which she complained of developing hyperpigmented macules on her face then she stopped taking medication.
After 2 days of stopping medication she again complained of developing bilateral pedal edema
Along with pedal edema she developed fever which was high grade continous in nature associated with chills since 5 days with no history of evening rise of temperature, no headache, no sweating.
Then she developed abdominal distension 8 days back which was insidious in onset, gradually progressed to present size.
Then she developed cough, which was insidious in onset, non productive.relieved on medication??
Then she developed decreased appetite one week back.
Then 5 days back she developed shortness of breath,insidious in onset, progressive in nature, to which she got admitted in other hospital and then she was referred to this hospital. She also had history of constipation and decreased urine output since 3 days.
then one day back she developed aphasia which was sudden in onset ,for which she was admitted in government hospital nalgonda ,but later shifted to our hospital.
Past history:- no similar complaints in the past and not a known case of diabetes mellitus, hypertension, asthma, thyroid, coronary artery disease, epilepsy, TB
Personal history:-
Mixed diet
Appetite lost
Non veg diet
Decreased bowel and bladder movements
Family history:- no significant family history
On Examination:-
Patient was Conscious, coherent, non cooperative well oriented to time, place and person. On admission vitals are.
RR 24cpm
Bp 110/70
PR 112bpm
Sp02 97%
Temp 99.8
On Respiratory system examination:-
On inspection:- normal shaped chest, trachea appears to be in centre, no scars and sinuses present,abdomino thoracic type of respiration, normal respiratory movements present
On palpation:- all inspectory findings are confirmed on palpation.
On percussion:- right left
Kornigs isthmus
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper, mid, lower
Interscapular
On auscultation:- normal vesicular breath sounds heard with inspiratory wheeze heard in all areas and left infrascapular crepts present
On CVS examination:-raised JVP, apex placed laterally, palpable thrill in Mitral area, loud S2 heard , pansystolic murmur in mitral area
Per abdomen:- soft and nontender, central umbilicus.
On CNS examination:- bilateral upper limb hypertonia with exaggerated deep tendon reflexes
CNS :
Right Handed person, studied upto 11th standard.
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
MMSE 17/30
speech :
Behavior :
Memory : Intact.
Intelligence : Normal
Lobar Functions :
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
gaze evoked Nystagmus present.
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK Normal Normal Normal Normal
TONE hypertonia hypertonia hypertonia hypertonia
POWER /5 /5 /5 /5
SUPERFICIAL REFLEXES:
CORNEAL present present
CONJUNCTIVAL present present
ABDOMINAL present
PLANTAR withdrawal withdrawal
DEEP TENDON REFLEXES:
R L
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 2+ 2+
KNEE 4+ 3+
ANKLE 2+ 2+
Patellar clonus present right side:- 4+
Left side:- 3+
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch
pain
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation.
steregnosis
graphasthesia.
CEREBELLAR EXAMINATION:
Finger nose test
Heel knee test
Dysdiadochokinesia
Dysmetria
hypotonia with pendular knee jerk present.
Intention tremor present.
Rebound phenomenon .
Nystagmus
Titubation
Speech
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT: hemiplegic gait
wide based with reeling while walking, unsteady with a tendency to fall
unable to perform tandem walking.
Provisional diagnosis:- Systemic lupus erythematosus (SLE)
On admission-27/09/2022
On 30/9/2022
Treatment:-
Summary:-
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.
A 20 year old female presented with chief complaints of
headache, neck pain since 3 days and
vomitings since 2 days
HOPI:- patient was apparently asymptomatic 3 days back the she developed headache which was sudden in onset, with dragging type of pain, diffuse, which worsened on following days, associated with neck pain, no aggravating and relieving factors.
Then she developed vomitings , 2 days back which was insidious in onset, with 3-4 episodes, non projectile, non bilious, food as content,not associated with pain abdomen and discomfort
No fever, no altered sensorium, No blurring of vision, No diplopia, No photophobia or phonophobia.
No history of trauma.
Past history:- diagnosed with SLE 2 months back,on tab. HCQ 200mg PO OD
Tab. Prednisolone 20mg PO BD ,tab.argoran 50 mg PO OD. No history of diabetes, hypertension, asthma
Family history:- father is diabetic
Personal history:- wakes up at 5am and sleeps early at 9pm doesn't perform any work, diet is mixed ,bowel and bladder movements are regular.
Dietary history:- took only grapes and milk following episodes of vomiting then admitted to ICu on 1-12-2022 , was on i.v fluids for two days, on 3rd for breakfast she had grapes , milk in afternoon and rice and curd for dinner, on 4rth breakfast and lunch had curd rice with bottleguard curry.
GENERAL EXAMINATION:- on informed consent of patient, she was examined in a well lit area, patient was conscious, coherent, cooperative well oreiented to time place and person.
Head to toe examination:-Facial puffiness present with stary look. Previous rashes subsided.
Echymotic patch noticed on Rt knee.
Neck stiffness present associated with Pain.
No pallor, icterus, lymphadenopathy, facial puffiness present, no cyanosis, clubbing.
Vitals at admission :
Bp 170/110mmhg
Pr : 84
Spo2 : 99 on RA
RR : 18 cpm
Temp : Afebrile to touch.
On CNS examination:-HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
MMSE:- 30/30
speech :
Behavior :
Memory : Intact.
Intelligence : Normal
Lobar Functions :
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
gaze evoked Nystagmus present.
On 3rd December:- diplopia was present subsided by evening
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK:- Normal Normal Normal Normal
TONE:-normal hypotonia normal hypotonia
POWER 5 /5 5/5 5/5 5 /5
SUPERFICIAL REFLEXES:
CORNEAL:- present present
CONJUNCTIVAL :-present present
ABDOMINAL:- present
PLANTAR :- flexor plantar reflex flexor plantar reflex
DEEP TENDON REFLEXES:
R L
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 2+ 2+
KNEE 3+ 3+
ANKLE 2+ 2+
Patellar clonus present right side:- absent
Left side:- absent
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch :-present
pain:- present
temperature:- present
DORSAL COLUMN SENSATION:
Fine touch :- present
Vibration:- present
Proprioception:- present
CORTICAL SENSATION:
Two point discrimination :- present
Tactile localisation:- present
steregnosis
graphasthesia.
CEREBELLAR EXAMINATION:
Finger nose test :- coordination present
Heel knee test :-present
Dysdiadochokinesia
Rebound phenomenon :- absent
Nystagmus
Titubation :- absent
Speech:- normal
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT: normal
Per abdomen:- inspection :- no visible scars, no engorged veins, no visible peristalsis
Palpation :- no organomegaly, no local rise of temperature and no tenderness. On percussion resonant and on auscultation bowel sounds were heard.
Provisional diagnosis:- lupus nephritis
Investigations:-24hr urine protein -1090 mg/dl (normal -less than 150mg/dl) on admission
Urine volume :-400 ml on admission
Blood urea :- 64
2nd December:- blood urea-84
4rth December:-blood urea- 73
On 4rth December:- urine volume was 150 ml
Treatment:-
On 1-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv BD
Tab prednisolone 20mg PO OD, 10mg PO OD
Syrup sucralfate 15ml PO BD
On 2-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv TID
Tab prednisolone 20mg PO OD, 10mg PO OD
Tramadal -1 amp IV
Normal saline -100ml IV
Syrup sucralfate 15ml PO BD
Injection mannitol-
100 ml IV
Injection monocef, trenexamic acid 2gm, injection vitamin K. 10 mg IV OD
On 3-12-2022
Tab paracetamol 500mg PO TID
Tab warfarin 5mg PO BD
Tab Hydroxychloroquine 200mg PO OD
Tab azathioprine 50mg PO BD
Inj zofer 4mg iv TID
Tab prednisolone 20mg PO OD, 10mg PO OD
Tramadal -1 amp IV
Normal saline -100ml IV
Syrup sucralfate 15ml PO BD
Injection mannitol-15 mg
Dexamethasone -8mg IV TI
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