drsaranya

Sunday, 7 November 2021

45 yr/ M with Fever ,Vomitings and Hypotension

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Introduction :

Here we shall discuss about a patient who is a 45 year old farmer hailing from South India .

PRESENTING PICTURE OF THE PATIENT :

Day 1

The patient presented to the OPD with complaints of

-Fever since 4 days

-Body pains since 3 days

-Reduced urine since 2 days

-Vomiting yesterday

-Black stools since morning

Please note : Patient was hypotension (70/40 mm Hg B.p was recorded ) on presentation and he was agitated, dyspneic ,was complaining of headache and was thirsty

Sequence of events which led to the presentation of the patient :

Patient is a farmer hence works in the farm from morning till eve, until 4 days back ( 29^th October 2021 ) when he developed fever along with cough ,headache. He received medications given by the local physician but nothing much changed

A day or two later he developed muscle pains which he described to be in both his arms and thighs and the fever was back again

He took medications for one more day

But nothing seemed to improve

Also a new addition to his problems were vomiting

This was when he was taken to Hospital1 where the attenders gave information about the patient being given fluids but they felt that proper care was not being taken and hence they brought the patient to Hospital2

When we asked more questions, we found out that he had passed much less urine than he usually does since the past couple of days and that day he had passed stools which were black in colour.

Daily Routine of the patient :

He normally used to get up at 5.00 am ,freshen up and go to the fields , in the afternoon at around 1.30pm he would return home for lunch, post which he took rest for an hour, by this time it would be around 3.00 pm

He would again go out for work for another 2 hours and then return home , take a bath ,have his meal .Many a times he would go out to drink alcohol in the evenings. After spending an hour or so talking to his wife and two sons over the meal

And then he would sleep by 9.00 pm.

Some more details about his complaints

High grade fever , intermittent and not associated with chills and rigors .

H/o 2 episodes of non projectile, non bilious, blood tinged vomiting yesterday

-Hematuria since morning

-1 episode of black tarry stool in the morning

-Reduced urine output since morning

Addictions :

He is an alcoholic since the past 20 years with around 90 ml of whiskey everyday. His last intake of whiskey was 4 days. He smokes around 2 packs of beedi everyday since the past 20 years.

GENERAL EXAMINATION :

PR - 118 bpm

BP- 70 /40 mm Hg ( started on fluids and ionotropes)

RR - 25 cpm

Spo2 - 92% on Room air

Afebrile

Lungs -

Inspiratory crepitations in Bilteral IAA,ISA

Cvs - S1,S2+

Per Abdomen -

Soft

Nontender

HB - 8 ( outside 2 days back 11g/dl)

TLC - 8400

Plt - 15,000

Total Bilirubin - 11

Direct Bil - 7.05

Ast - 327

Alt - 187

Alp - 303

Albumin - 2.4

Serum creatinine - 2.5

NOTE : There is history of change in water source and also contamination of right ankle with rat's urine in his farmlands

Fever Chart

Fever Chart (updated : Day 6 of Admission 8th November 2021 )

Chest X ray on Day 2 (4th November 2021 )

Chest Xray on Day 4 of Admission : 6th November

Some textbook description of Weil's Disease :

Courtesy declaration: The following images are not original and have been taken for reference from the below mentioned source .

Source : Davidson's Principles and Practice of Medicine

23^rd Edition

Infectious Diseases

Note : On 5th November 2021 evening ,patient developed Cardiac Arrest owing to the Myocarditis entity and was revived by cardiopulmonary resuscitation.

UPDATE :8th November 2021

http://prashanthsharma101.blogspot.com/2021/11/case-of-45-years-old-man.html

Patient is having fever spikes , cough with sputum yellow coloured,non blood stained ,shortness of breath , generalized bodypains .

Yesterday night - patient had one episode of high grade fever with chills ,became tachypneic .

Connected to NIV - CPAP.

ABG with high flow oxygen showed Hypoxia ,hence

Patient was on CPAP PC mode overnight

With RR- 33/ min

Peep - 7

Fio2-50%

icteric,pallor, subconjunctival hemorrhage

Afebrile

PR-90/ min ,regular

BP- 130/90 mmhg

RR-37 / min

Spo2- 100% with fio2-80%

RS- BAE present ,bilateral crepts + infraxillary ,infrascpular regions .

CvS- S1,S2 heard

P/ A soft

1-MODS- weils syndrome

2- Ventilator Associated pneumonia ?

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

TEMP charting ,vitals monitoring.

In view of persistent fever spikes ,hypoxia , tachypnea,new radiological opacties -Emperical antibiotic coverage for VAP was started with levofloxacin and vancomycin .

Sunday, 31 October 2021

38/F with Seizures and Other CNS Findings.

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Introduction :

Here we shall discuss our patient who is a 38 year old lady hailing from a village in South India .She is a tailor by occupation.

Presenting Picture of the patient :

BACKGROUND

Almost all her 38 years of life have been if a different shade as compared to any other of her contemporaries.

This is because when she was 3 year old ,one day she experienced fever for a day and then the next day she developed inability to move both her lower Limbs.

Since then she has grown up with the help of mechanical support to substitute her lost power in her lower Limbs.

Fast Forwarding to 20 days before the day of presentation to our Hospital ( henceforth shall be referred to Hospital2)

She developed high grade fever , cough with sputum , headache.

She took medications prescribed by a local physician

After a couple of days , since any of the symptoms mentioned above weren’t subsiding

She was taken to a local hospital ( Hospital1 )

There the attenders were told that she has low hemoglobin ( 5gm/dl ) and was transfused 3 units of packed cells .

Post other medications administered by Hospital 1 her fever subsided but other problems did not.

4 days prior to presentation to Hospital 2

She developed weakness in her Right upper limb and Right lower Limb , slurred speech and disorientation.

She also had seizure episode that night and couple of days even after that.

She was taken to the same Hospital1 once again where they referred her to Hospital 2 and thus she presented to us.

Note : No seizure episode has been witnessed since admission to Hospital2 on 30.10.21.

DESCRIPTION OF THE DAY THE PRESENT ILLNESS DEVELOPED :

Since she was not keeping well since the last 20 days ,her husband used to keep a check on her health via telephone from his workplace ( a restaurant cook )

On his call that day , she mentioned to him that she wasn’t feeling quite well ,and by the time he returned home after work ,he reports that her eyes had a blank stare , she could identify him but she spoke few words which were slurred ,did not carry any meaning and then she stopped speaking .

Some time later she threw a seizure episode wherein her husband gives history of eye rolling and tongue bite.

After which she was taken to Hospital 1 and then Hospital 2.

CHRONIC DISEASES :

She is not a known case of DM ,HTN ,Bronchial Asthma ,TB, Thyroid.

DAILY ACTIVITIES :

She consumes mixed diet , with a slightly lessened appetite since the past fortnight , sleeps adequately , bowel and bladder Normal

No history of any involuntary passage of urine or stools

She is not a smoker ,she doesn’t consume alcohol.

No known food or drug allergies.

FAMILY HISTORY :

No similar complaints in any of her immediate family members.

No history of sudden deaths in the family.

EXAMINATION

General examination :

Positive findings :

Pallor present.

Generalized edema present.

Hyperpigmented knuckles.

VITALS :

Body temperature: Afebrile

Pulse : 80 bpm

B.P : 130/70 mm Hg

R.R. : 16 bpm

On auscultation :

S1 , S2 heard.

Diffuse wheeze heard in all lung fields.

Abdomen soft and non tender.

CNS FINDINGS :

Patient is conscious ,but NOT coherent .

She is disoriented.

She is aphasic.

R L

TONE UL Hypotonic Normal

LL Hypotonic Hypotonic

POWER UL 1/5 3/5

LL 1/5 2/5

REFLEXES

B T S K A P

R 1+ - - - - Extensor

L 1+ 2+ - - - Extensor

Babinsky Positive in Right limb.

INVESTIGATIONS :

Tuesday, 26 October 2021

62/M Repeated Episodic Paralysis of Limbs.

Greetings to all my readers.

I am Saranya , a final year MBBS student.

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

DATED : 26th October 2021

CONSENT AND DEIDENTIFICATION :

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

PRESENTING PICTURE OF THE PATIENT

A 62 year old man ,farmer by occupation, hailing from South India, presented to us on 23^rd of October 2021 with complaints of weakness of both lower Limbs till level of knee since the night before.

ELABORATING ON HIS PRESENTING COMPLAINT :

Although the present acute attack began just a night before the day of presentation of the patient to us ,his illness seems to date back to 2K18 when one fine day ,while at home ,after he came back from his daily field work, suddenly there was onset of weakness in both is lower Limbs, along with slurring of speech which continued for a duration of 2 days and then resolved post medications administered by the physicians at Gandhi Hospital.

Post this first episode of 2k18 ,he returned into his normal routine within 4 days ,and everything went unexceptional until 2k19 when a similar episode was witnessed by him again , but this time there was no slurring of speech.

Following the previous trend,he was hospitalized but was back to normalcy within the next 2 days.

The present acute episode happened in the late hours of 22^nd October 2021 .

DESCRIBING THE DAY ON WHICH THE LATEST EPISODE OOCCURED.

22 October 2021

He was mentally disturbed since the past one week due to the death of one of his close relative ,which the patient feels was responsible for him having accentuated his daily alcohol intake

On this day he had done quite a lot of work at his field and some other significant outdoor activity following which in the evening he came back home ,when he complains of having felt feverish.

Nevertheless he freshened up ,had his dinner, consumed about 100 _ of toddy and went to sleep.

He had got up once to pass urine when he did not feel anything abnormal in himself

But the second time when he felt the need of getting up once again to pass urine he realized what his left lower Limb did not have any strength at all ,in the next moment his right limb also felt weak

He also felt weakness in both his upper Limbs.

No problem was felt in speech or articulation

In this state he was brought to us,in the early hours of 23^rd October 2021.

CO MORBIDITIES :

He is not a K/C/O Hypertension,Diabetes Mellitus,Bronchial Asthma,Coronary Artery Diseases or Epilepsy.

He has normal appetite ,takes mixed diet,bowel and bladder normal, gets adequate sleep.

No known food or drug allergies.

ADDICTIONS :

Not a smoker.

He consumes toddy daily since the last 30 years ( 90 daily) But has increased his daily consumption since the last few weeks.

FAMILY HISTORY : No similar complaints in any of his relatives.

GENERAL EXAMINATION :

ABNORMAL PARAMETERS IN THE LABORATORY WORK UP :

Serum Creatinine 2.2 mg/dl

Serum Potassium 2.4 mEq / l

Serum Magnesium 1.7 mg /dl

Total Bilirubin 1.15 mg/dl

Direct Bilirubin 0.36 mg/dl

Alkaline Phosphate 174 IU / L

CBP :

DISCUSSION THREADS :

* How to differentiate between similar presentations due to inflammation mediated attack on myelin sheath of nerve fibres and those due to electrolyte Imbalance?

* What is causing recurrent dyselectrolemia in the patient?

Wednesday, 30 June 2021

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.

Monday, 7 June 2021

A 27 year Old Male with Acute Abdominal Pain

EXPECTATION FROM THIS E LOG :

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 .