Long case - final practical

-

Hall ticket no. 1701006160

Long case 

       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 options

Following is the view of my case :

FEVER WITH HEADACHE

A 55 year old female, resident of nalgonda district, labourer by occupation came to hospital on 9 th June 2022.


C/O :   
  1. Headache since 20  days 
  2. Fever  since 5 days 
  3. Neck stiffness since 5 days 
HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back, then she developed 
  1. Headache : insidious onset, gradually progressive, not relieved on medication (medicine taken from a local doctor) The headache aggravated 5 days back I spite of taking medication. No aggravating factor. 
  2. Fever : insidious onset, since 5 days, intermittent fever , not relieved on medication she took at home. Not associated with chills / rigors. 
  3. Neck stiffness : insidious onset, gradually progressed. 
  4. Vomiting : one episode, 3 days back, non projectile, non bilious, food as content, non blood stained. 
No abdominal pain, diarrhea, cold, cough. 




PAST HISTORY :

-Paralysis of bilateral upper and lower limbs 7 years back. She was treated for paralysis in various hospitals. She recovered in 6 months. 
-Back pain since 2 months. Takes medicine when it's severe. 
-No h/o hypertension, asthma, epilepsy, tuberculosis. 
-Denovo detected diabetes. 
-No h/o surgeries. 

PERSONAL HISTORY : 

Diet : mixed 
Appetite : normal 
Bowel / Bladder : regular 
Sleep : adequate 
Addictions : none 

FAMILY HISTORY : 
Not significant. 

GENERAL EXAMINATION : 

-Patient is explained about the examination and consent taken. 
-Patient is conscious, coherent, cooperative 
-No signs of pallor, Icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 








VITALS : 
Pulse rate : 75 bpm
Respiratory rate : 15 cpm 
Blood pressure : 120/70 mm of Hg 
Temperature : afebrile 

CNS EXAMINATION : 

Higher mental functions : 
-Patient is conscious, oriented to time and place 
-Memory is intact
-Speech and language normal
 
Cranial nerve examination : 
-2 nd cranial nerve : Visual acuity - counting fingers from 6m distance 
-3,4,6 cranial nerves : extraocular movements present, direct indirect reflexes present. 
-5 th cranial nerve : sensations over face present 
-7 th cranial nerve : forehead wrinkling present, able to blow cheek, able to open and close eyes, Naso labial folds normal 
-8 th cranial nerve : hearing normal, no Nystagmus. 
-9, 10 th cranial nerve : uvula centrally placed and symmetrical. 
-11 th cranial nerve : trapezius and sternocleidomastoid normal 
12 th cranial nerve : tongue no deviation. 

Motor examination : 
                                                    
1.Bulk 

Inspection and palpation normal
Right                         Left 
   - MUAC 28 cm 27.5cm 
   - mid forearm 20 cm 20 cm
   - mid thigh 29 cm     30 cm
   - mid calf 25 cm 25 cm 
    
2.Tone 
 - upper limb normal normal 
 - Lower limb    normal normal 

3.Power 
- upper limb    5/5                       5/5 
- Lower limb 5/5                       5/5     

4.Reflexes
 - knee jerk  + +
 - Ankle jerk + +
 - Biceps + +
 - triceps + +
 - Plantar normal normal 

Meningeal signs :
1. Nuchal rigidity :  present 
2. Kernig sign :  positive 
3. Brudzinski sign :  positive  

Sensory examination  -  Normal 


Cerebellar examination - Normal 







  
RESPIRATORY EXAMINATION : 
Bilateral air entry present 
Normal vesicular breath sounds heard 

CVS EXAMINATION : 
S1 and S2 heard 
No murmurs 

ABDOMINAL EXAMINATION : 
Soft, non tender abdomen 
No organomegaly 

INVESTIGATIONS : 

Hemogram : 


Dengue : Ns 1 antigen 


 
CSF analysis : 

Sugar : 81
Protein : 12.6




Arterial blood gas analysis : 

PH : 7.4
PCo2 : 29.1
PO2 : 88.4
HCO3 : 18

Fasting blood sugar - 168 mg/dl  

Complete urine examination : 

Albumin : positive 
Sugar : nil 
Pus cells : 6-8
Epithelial cells : 3-4
RBC and casts : nil 

Renal function test : 

AST : 69 IU/L
ALT : 68 IU/L
ALP : 135 IU/L
Total protein : 6.4 gm/dl
Albumin : 4.0 gm/dl
Urea : 38 mg/dl
Creatinine : 1.0 mg/dl
Uric acid : 4.9 mg /dl

Serology : Non reactive 

Xray neck : 


Xray : knee joint 



MRI of brain  : 




X ray of chest : 



PROVISIONAL DIAGNOSIS: 
Dengue fever with meningoencephalitis 

TREATMENT : 
9 th and 10 th June 2022     
Injection ceftriaxone 2 gm / ml BD 
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous TID
Tab ecosporin 7 mg per oral OD 
Tab cremaffin 30 peroral 

INVESTIGATIONS ON 12 JUNE : 
Hemogram : 
Hb- 13.1
Tlc-16,400 /mm3 
Neutrophils- 82
Leukocytes -9
Eosinophil -1
Monocyte -8
Platelet count -1.81lakh/mm3 

Arterial blood gas analysis : 
PH - 7.44
PCO2 - 28 
PO2 - 49.3
HCO3-18.7
O2 sat - 85.1



TREATMENT : 

Intravenous fluids NS and RL 
Injection ceftriaxone 2 gm / ml BD 
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous SOS
Tab paracetamol 650 mg TID
Tab ecosporin 7 mg per oral OD 
Tab cremaffin 30 peroral 
Tab metformin 500 mg per oral 










Comments

Post a Comment

Popular posts from this blog

A 14 year old female with SOB snd fever

-
Image
    This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s 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 patients clinical problems with collective current best evidence based inputs.       This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome . Note:  The cases have been shared after taking consent from the patient/guardian. All  names and other identifiers have been removed to secure and respect the privacy of the patient and the family. Consent:   An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references Patient came to casualty with C/O: 1) Shortness of brea...
Read more

Medicine Internal assessment

-
Image
10 Marks questions: Question - 1  Define bone density, how is it measured? What are the causes, clinical features,diagnosis and management of osteoporosis? (1+2+2+2+3) https://rishik37.blogspot.com/ 2021/08/gm-elog-case-7.html  ( 31st aug, 3:39pm) Question - 2   What is myxedema coma? Describe its clinical features , diagnosis and treatment of myxedema coma (2+2+2+4)   http://mahithguduri63. blogspot.com/2021/09/myxedema- coma.html(  22nd sep, 9:36am) 4 marks questions : Question - 3  What is the diagnostic approach of young onset hypertension and it’s treatment. http://keerthykasa80.blogspot. com/2021/09/a-35-year-old- female-with-hypertensive.html( 22nd  sep, 10:24am ) Question - 4  How do you clinically localize the anatomical level of lesion in spinal cord diseases. http://sowmya9.blogspot.com/ 2021/08/21-year-old-with.html( 2nd  sep, 7:27pm)   Question - 5  C auses,diagnosis and treatment of atrial fibrillation. (Shared on 25th...
Read more

A 56 year old male with altered sensorium and CKD

-
Image
A 56 Yr old male R/o Miryalaguda,  dialy labourer by occupation came to hospital on 19 November 2021 for his dialysis  Hopi :  Patient was apparently asymptomatic 2 years back when he was diagnosed with CKD when he had c/o bilateral pedal edema  Patient has come to the hospital for his regular dialysis session on 19 Nov, after running regular tests he was told he requires blood transfusion.  Dialysis session was delayed due to blood transfusion ( the last dialysis session was 14 days back).  Patient developed fever since 3 days associated with chills and rigors and increased during night. No associated vomiting, diarrhea, shortness of breath.  Patient's relative noticed slurring of speech and not responding to commands since 1 day  Past history :  H/o hypertension and diabetes mellitus since 4 years.  Diagnosed with CKD 2 years back, for which he is on dialysis twice a week  H/o blood transfusions 2 times in the past, recent one is ...
Read more