An apparently simple case but with a Twist

 

A TELEMEDICINE PATIENT CENTRED DOCUMENTATION

A note before we begin :

This is 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 best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

What the readers can expect from this piece of document :

This case was a telemedicine based one whereby , I ( under the guidance of my teacher ) tried to converse, understand the problem being faced by the patient and advice her regarding the relieving measures ( while mentioning her to consult a physician or a nearby health care institution in case of emergency )

this is a CONVERSATIONAL E-LOG

i.e  I shall sequentially arrange the learning conversation that went on between the mentor and mentee..to project and highlight how one single patient can trigger thousands of learning possibilities and open up innumerable closed doors to lead to the pinnacle of knowledge.

DEIDENTIFICATION : Please note that the participants of the conversation have been deindentified

HP : Mentor

MN : Mentee

[10:09 AM, 7/1/2021] Mentor : Can any of our student members here take the details of a middle aged woman told to have a BP that is very low, pulse thready with borderline diabetes so that we can understand her current requirements and then advice her? 

A similar exercise was recently carried out in this group and archived here https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html?m=1

Pm me for her phone number if anyone is interested in the above exercise of improving learning outcomes to drive real patient health outcomes

[10:09 AM, 7/1/2021] Mentor: 👆if you are planning to call her later she would prefer evening

[10:09 AM, 7/1/2021] Mentor: Some literate pateints can even be texted

[10:09 AM, 7/1/2021] Mentee: Ok sir

Will call her in the evening.

[10:09 AM, 7/1/2021] Mentee: Sir

The patient you had spoken to yesterday...

The referral  

She has bp of 110 /60

[10:09 AM, 7/1/2021] Mentor: Feedback from my friend (who is also her friend) 

"Spoke to the Dr student.  Thanx i felt better just speaking to her   "

Well done 👏

[10:09 AM, 7/1/2021] Mentor: Very well done audio as well as overall consultation. 

I think it will be a good idea to make some audio case reports (first time in the world?) and E log them to share them widely as learning insights into Telemedicine. Take a signed informed consent for it if possible although the patient is already perfectly deidentified here so it may not be necessary. You can even try audio visual consent taking as it would gel with the national bioethics research guidelines 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5799953/

[10:09 AM, 7/1/2021] Mentee: Her blood pressure today is 104/72 mm Hg

[10:09 AM, 7/1/2021] Mentee: Sir 

I told her not to take antihypertensive meds today as well

Maybe we can start from tomorrow

[10:09 AM, 7/1/2021] Mentor: Ask her to monitor it regularly and take it only if it goes above 135/85 among the average of all her daily readings. 

Maybe she never needed the antihypertensives in the first place? How long has she been told to have hypertension?

[10:09 AM, 7/1/2021] Mentee: For the past 3 years sir

[10:09 AM, 7/1/2021] Mentor: Let's monitor and see. 

Maybe she never needed it

[10:09 AM, 7/1/2021] Mentee : Sir

Her b.p. is being somewhere around 120/70 mm Hg

[10:09 AM, 7/1/2021] Mentee: But it has been more than a week she is without her meds

[10:09 AM, 7/1/2021] Mentee: Should we start her on half dosage of what she used to have previously sir?

[10:09 AM, 7/1/2021] Mentor: Let's ask her to monitor and let us know how many times it's going above 140'/90.

She needs to monitor at least ten times a day at random intervals

[10:09 AM, 7/1/2021] Mentee: Ok sir

[10:09 AM, 7/1/2021] Mentee: She usually takes this antihypertensive combination sir( telmisartan + Chlorthalidone )

[10:09 AM, 7/1/2021] Mentor : The chlorthalidone can cause dangerous hyponatremia

[10:09 AM, 7/1/2021] Mentee: Yes sir!!

Even telmisartan proves to be too sensitive to many patients sir

Y not keep her on losartan twice daily?

[10:09 AM, 7/1/2021] Mentor: Anyway she is not that much of a hypertensive

[10:09 AM, 7/1/2021] Mentee And because of the long acting effect of Telma she is having these readings maybe

[10:09 AM, 7/1/2021] Mentee: And even after that if she needs titration we can add a beta blocker once daily

[10:09 AM, 7/1/2021] Mentee: That too she is on telmisartan 80 mg !!!

People get hypotensive phases with 40 mg itself sir!!

[10:09 AM, 7/1/2021] Mentee: That patient

[10:09 AM, 7/1/2021]  Mentee: Developed pedal edema as well

[10:09 AM, 7/1/2021] Mentee: Pitting type till the ankle

[10:09 AM, 7/1/2021] Mentee : I guess the chlorthalidone was helping her edema till now. 

Mentor :What may have been the cause for her edema? Hypoalbuminemia or heart failure or idiopathic edema of women?

[10:09 AM, 7/1/2021]Mentee:  We need to get investigations done for that..

[10:09 AM, 7/1/2021]Mentor: Before that can we have her history from earlier let's say from the time she first met a doctor and was detected hypertensive or even earlier from her childhood?

[10:09 AM, 7/1/2021]Mentee : Ok sir

[10:09 AM, 7/1/2021]  Mentee:Will talk to her today

[10:09 AM, 7/1/2021] Mentor: Chest X-ray 

Ecg 

Echocardiography 

(even in the past if available)

Video of her neck veins in the 90 degree sitting position 

Serum albumin (even in the past if available)

[10:09 AM, 7/1/2021] Mentee: Ok sir

Urea 

Creatinin?

[10:09 AM, 7/1/2021]Mentor: Any past report of complete hemogram

[10:09 AM, 7/1/2021] Mentor: Yes just creatinine will do

[10:09 AM, 7/1/2021] Mentee: Okkay sir

[10:09 AM, 7/1/2021] Mentee: Sir

[10:09 AM, 7/1/2021] Mentee: That patient

[10:09 AM, 7/1/2021] Mentee: She got dyspneic

[10:09 AM, 7/1/2021]  Mentee: Maybe coz of the fluid overload!

[10:09 AM, 7/1/2021] Mentee: She has a history of huge steroid intake

[10:09 AM, 7/1/2021] Mentee: To treat her psoriasis

From a naturopathy doctor

[10:09 AM, 7/1/2021] Mentor: Possible heart failure. 

Why was she on steroids?

[10:09 AM, 7/1/2021] Mentor: How do we know it was steroids as naturopath doctors are not supposed to be prescribing it

[10:09 AM, 7/1/2021] Mentee: I told her to resume her medicine

And in the mean time get the investigations done

[10:09 AM, 7/1/2021] Mentee: No sir

It's a long story

I will tell you completely ,give me some time sir

I ll talk to her some more

[10:09 AM, 7/1/2021] Mentor: Hope you asked her to remain in touch with a local physician in case of emergency

[10:09 AM, 7/1/2021] Mentor: When did she first notice her psoriasis? When did the tea company doctor first prescribe her medications for her ankle swelling? Was the dyspnoea noticed by her today for the first time?

[10:09 AM, 7/1/2021] Mentee: Ans 1.  3 years back

Ans 2. Around 2 back.

Ans 3. Today.

[10:09 AM, 7/1/2021] Mentee: *2 years

[10:09 AM, 7/1/2021] Mentor: No past history of asthma? 

What drugs did the previous doctor prescribe two years back? How long did she take them?

[10:09 AM, 7/1/2021] Mentee: Goodevening sir

Sir that lady...your colleague's acquaintance..

She has given her blood sample for investigation..

Reports awaited..

The technician has said after doing the ecg and 2D echo that all is fine it seems

Though official report and strip is awaited .

She had resumed taking her medication due to the fluid accumulation..edema..and SOB

But her b.p is low only sir ..

110/60 mm Hg on an average

Could u help me regarding what I should comment about her taking the meds and the existing low b.p

[10:09 AM, 7/1/2021] Mentor: 110/60 should be OK. 

She should just take care it doesn't fall below 80/50

[10:09 AM, 7/1/2021] Mentee: Sir

One more thing I wanted to share with you

Remember the patient who was your friend's friend..

The lady with low B.p ?

She used to send him her b.p.readings every morning..and update about her health and all

Once the topic of the locations of residences had come up

And then yesterday she sent me a cake which she had herself baked.

[10:09 AM, 7/1/2021] Mentee: I felt so humbled

I told her many times that her regard was enough ,the cake wasn't needed at all

But she had already baked and sent it

[10:09 AM, 7/1/2021] Mentor: Tell her to send healthy fruits and vegetables next time as cakes and all other baked products are unhealthy and possibly responsible for her hypertension and other NCDs that emerge from the visceral fat driven adipokines. 

[10:09 AM, 7/1/2021] Mentee: 

She is home baker sir.. she finds joy in baking.. maybe I ll make her sad if I tell her to stop her hobby :( but definitely I tell her not to consume her bakery products :)

[10:09 AM, 7/1/2021] Mentee: Sir

Thankyou for letting me have the opportunity to interact with my patients

To understand them

And to get all the love from them

[10:09 AM, 7/1/2021] Mentor: This is psychotherapeutic redirecting challenge. Take up this challenge with Mahima to redirect her cooking joy in a healthier direction?

[10:09 AM, 7/1/2021] Mentee: Will try sir.

A 27 year Old Male with Acute Abdominal Pain

 

EXPECTATION FROM THIS E LOG :

This is 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 best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

I thank Dr. Chitra , for providing me with every detail about the patient , and also being extremely patient with my doubts about the case. 

Introduction : 

The Patient is a 27 year old Male , a Post Office Employee  in Telangana .

Chief Complaint :  

The Patient presented to the Casualty on 5th June 2021 with complaints of Pain in Upper Abdomen since the morning of that day.

History of Presenting Illness :

( Certain Past Events shall also be mentioned here , if they have a role in the present manifestation of the pathology )

The patient has been an Alcoholic since 5 years , with a daily intake of about 180 ml of Whiskey .

The Patient developed pain in the Upper Abdomen in the early morning hours of 5th June 2021 and was rushed to the hospital.

Pain was sudden in onset , rapidly progressing , aggravated ( burning sensation ) by spicy/heavy food intake , no relieving factors as such.

He described the pain to be diffuse , radiating to the back .

Not associated with

Nausea/ Vomiting

Shoulder Tip Pain

Distended Abdomen.

 

Last History of Alcohol Intake : 2nd June 2021

Past History :

No similar Complaints of Acute Abdominal Pain in the past,.

In 2014, he had had an acute attack of SOB,triggered by cold exposure , had got relieved on medication .

He was prescribed Inhalers but is not compliant to the same.

In 2015, he had an episode of Epilepsy , for which he is under medication .

He is not a K/C/O  DM , HTM , CAD .

Personal History :

Appetite is normal ,

Takes Mixed Diet,

Bowel and Bladder : Normal

Sleep : Adequate

Does not Smoke

Is a Regular Alcoholic since 5 years ( details mentioned above )

No known food or drug allergies .

He is less tolerant to cold exposure / cold food/drinks . (Asthma Trigger )

Family History : 

Not Significant.

Treatment History :

  Has had a Surgical repair for Inguinal Hernia 4 years ago.

NOTES : 

EXAMINATION :

GENERAL EXAMINATION :

The patient was examined in both sitting and supine position  after obtaining Consent . Examination was done in a well lit room , in the presence of an attendant , with adequate exposure .

Patient in Pain .Wincing Expression . ( Wong Baker's Rating : 8 ) .

Patient is not still on bed.

The patient is of moderate nutrition and built. 

TRUNCAL OBESITY PRESENT.

Conscious , Coherent , Cooperative . Oriented to time , place and person.

He does not have

Pallor, Icterus , Cyanosis , Koilonychia , Clubbing ,Generalised Lymphadenopathy ,Pedal Edema.

VITALS on Presentation :

Pulse : 110 bpm , normal Rythm , volume , condition of vessel wall , without any delay.

B.p :   130 / 80 mm Hg recorded in the Right Brachial Artery in supine position

R.R : 22 cpm

Body Temp. : Afebrile .

SpO2 : 98 % on r.a.

Pain : Present , Rating 8 ( Wong Bakers Rating ).

SYSTEMIC EXAMINATION :

CVS : normal


RESPIRATORY SYSTEM : normal


CNS : normal


ABDOMEN :  Abdomen soft , tender.

Note : Tender Abdomen .Abdomen is distension has increased . On 6/June/2021 night : Resonant note was obtained up to 3 cm above the umblicus but

On 7/jun/2021 morning : Resonant notes percieved till below the umblicus.

Shifting Dullness present .

INVESTIGATIONS :

Complete Blood Count

Urine Sample 

COMPLETE URINE EXAMINATION

COAGULATION PROFILE :

LDH raised

SERUM LIPASE raised

SERUM AMYLASE raised

Normal Random Blood GLucose

LFT

RFT and ELECTROLYES

CHEST RADIOGRAPH

RYLE'S TUBE ASPIRATE.

FEVER CHART

ULTRASONOGRAPHY REPORT

CROSS CONSULTATION NOTES : 

Provisional Diagnosis : A 27 year old man , chronic alcoholic with acute pancreatitis and Grade II Steatohepatitis .

INTERVENTIONS DONE :

Plan of Management : Conservative.

Communication with Attenders :  Outcome has been adequately explained .

Medications :

UPDATED : ( 9th June 2021 )

             

i

A Case of COVID 19 Pneumonia

 Introduction :  

This is 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 best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

Regards to Dr. Anjali who has guided me and provided me with the information about the patient.

An Outline about the Patient : 

He is a 51 year old gentleman from a village in South India.

Chief Complaints : The Patient presented on 1/06/2021 with Cough since 6 days , Chest Pain since 4 days

History of Presenting Illness :  

The patient was apparently asymptomatic 6 days back when he developed Cough ( wet )  .It was insideous in onset . The expectoration was minimal in amount , mucoid in consistency , non foul smelling , non blood stained . Not aggravated or relieved with posture.

He developed Chest pain 4 days back , sharp in nature , not radiating to back , or upper limb . Pain aggravated on respiration movements of the chest and on coughing as well , no relieving factors as such.

COVID RTPCR done at the hospital on 3/6/21 and  positive results obtained.

There is no History of 

Shortness of Breath

Hemoptysis

Fever

Body Pains

Fatigue

PAST HISTORY :

  History of  previous infection with COVID 19 on 13/05/21 , for which he had been hospitalized and was given O2 Support for 5 days before his discharge on the 6th Day.

He is a K/C/O  DM, ( Since 9 years , takes Glimiperide 2mg , Metformin 500 mg BD )

HTN ( Since 3 years , takes Amlodipine 5 mg O.D )

No past H/o CAD , Asthma , Epilepsy .

PERSONAL HISTORY :

He has normal appetite ,

Takes Mixed Diet

Sleep slightly disturbed due to Cough 

Constipation since the last 5 days.

Not an alcoholic.

Used to Smoke but stopped 12 years back. 

No known Allergies.

Family History : 

Contacts being traced for any COVID  infected indivual ( if any ). 

GENERAL EXAMINATION : 

Done after obtaining consent , in a well lit room , in the presence of an attendant , with adequate exposure .

No pallor , Icterus , Cyanosis , Clubbing , Koilonychia , Generalised Lymphadenopathy or Pedal Edema.

 

VITALS  : 

RADIOLOGICAL INVESTIGATIONS : 

ECG :

REPORTS :  

MONITOR READING :  

PROVISIONAL DIAGNOSIS :

UPDATE :
7/JUNE/2021

Patient Discharged