G.Sai Varun 

hall ticket no. 1601006061

"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. 

I've 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 a diagnosis and treatment plan. 

        CASE OF RHF DUE TO LUNG PATHOLOGY 

A 46yr old female, housewife resident of Nalgonda came to the hospital with chief complaints of shortness of breath since 5days 

History of present illness

  She was apparently asymptomatic 5days back then she developed shortness of breath which was insidious in onset, gradually progressive, aggravated on lying down, and relieved on medication.

Associated with orthopnea, wheeze, paroxysmal nocturnal dyspnea 

Anasarca since 5days and cough with expectoration since 5days which is insidious in onset

Past history

K/c/o Copd since 12yrs and is  on inhaler

 General examination 

Raised JVP 

Respiratory examination 

Inspection-normal

Palpation- normal

Auscultation - bilateral decreased breath sounds and bilateral rhonchi and crepitations present at infrascapular, infra axillary areas

CVS examination 

Inspection -normal

Palpation

*left parasternal heave

*Palpable p2

*apex beat 5th ICS lateral to the midclavicular line

Auscultation

*S1, S2 present

*Loud p2

 

Findings

The right atrium and right ventricle dilated

RVSP 85mmhg

Severe TR with PAH

G.Sai Varun

hall ticket no. 1601006061

    

"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.                                                          

I've 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 a diagnosis and treatment plan. 

                                              CASE OF LIVER ABSCESS 

CASE:  A 55year old male patient, resident of miryalaguda, who is a toddy climber by occupation came to the medicine out patient department with Chief complaints of pain abdomen and fever.

chief complaints 

1) Severe pain abdomen since 10 days.

2) Fever since 7 days.

history of present illness

                       Patient was apparently asymptomatic 10 days ago and then developed - pain abdomen in the right hypochondrium ,which was sudden in onset, gradually progressive , dragging type and non radiating pain. It is aggravated on standing and relieved for sometime upon taking medication.

Not associated with nausea, vomiting, loose stools.

-And then  he developed fever since 1 week which was high grade, continuous type and associated with chills and rigor. It is not associated with Cold, cough, shortness of breath ,giddiness, headache and sweating. It is relieved  upon taking medications

-No complaints of chest pain, palpitations and burning micturition.

HISTORY OF PAST ILLNESS:

                       Patient was admitted in the hospital for 3 days with similar complaints 14 days back and was given IV antibiotics for 3days.

 There is no history of DM/HTN/EPILEPSY/ASTHMA/CVA/CAD.

Treatment history:

 3 day high dose  antibiotics course given 14days back.

PERSONAL HISTORY:

               Sleep: adequate

               Diet: mixed 

               Appetite -decreased since 1 week

               Bowel and bladder -Regular 

               micturition -normal

               Addictions - toddy consumption-  1litre/day since 35years.

                                  -Tobacco in the form of beedi- 10/day since 30years

Patient practices open defecation at a well near his working place.

FAMILY HISTORY: 

There is no relevant family history

General physical examination:-

-Consent has been taken from the patient for examination

The patient is conscious, coherent and cooperative, sitting comfortably on the bed.

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

- He is moderately built and moderately nourished.

Vitals:

- Temperature = he is now afebrile

- Pulse = 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay.

- Blood pressure = 110/80 mm of Hg

- Respiratory rate = 16 cycles per minute.

- JVP is normal

-mild icterus is seen on sclera

- pedal edema is noticed of pitting type 

                                               •progressive in nature 

                                               • extent up to ankles

- There is no Pallor, Clubbing, Cyanosis, and Generalized lymphadenopathy 

-Spo2 -96% on room air 

-RR- 16 cpm

-CVS -S1b& S2 heard; no murmurs 

- RS-decreased air entry in right infraaxillary and infrascapular region  and bilateral fine crepitations are present in right lower lobe.

Abdomen examination:

INSPECTION

- SHAPE of the abdomen: scaphoid

- no visible scars and sinuses

- no engorged veins

- no visible pulsations 

- umbilicus is central 

PALPATION
- no local rise in temperature

- tenderness in the right hypochondriac region of abdomen noticed.

- no organomegaly 

PERCUSSION

- There's no free fluid level

AUSCULTATION

- bowel sounds heard on auscultation

- no bruit heard 

INVESTIGATIONS

CBP

LFT

RFT

culture and sensitivity

chest x-ray 

right sided pleural effusion can be seen 

USG ABDOMEN 

PT and INR

aPTT

 

Treatment received

- metronidazole

-thiamine

-clindamycin

-tramadol

-ampicillin

-pantoprazole

PROVISIONAL DIAGNOSIS

Based on right hypochondrium  pain, fever  pedal edema and mild icterus and investigations the anatomical location of the problem confines to Liver.

Based on history of the patient and ultrasound findings my provisional diagnosis is liver abscess.

A 42 year female with quite a few complaints dating back to her childhood

hello all, I am currently doing my final year of MBBS and this is a log to share my views of an interesting case



presenting problems:

  She presented to us with the problems of  1. frequent fall to the left side with weakness in left hand  and leg

 2. she had salt and fat cravings

 3. she had hair loss and fatigue

 4. poor stress response  

 5. she had generalised swelling due to emotional stress, exercise, smoking, eating

 6. she had decreased sleep

 7. she complaints of decreased urine output

 8. left jaw pain

 9. difficulty breathing
Her past problems:


- severe jaundice during birth
- decreased sleep
- severe reaction to sulpha drugs
- wake up at nights due to raise in heart rate
- anxiety issues
- migraines
- weight fluctuation
- ectopic pregnancy
- pcod
- kidneys and lung infections
- removal of precancerous tissues
- anemia in the past
- reaction to antimalarials
- reaction to fava beans
- has history of heavy mensutral bleeding
- dark coloured urine after exercise

family history:

mother was diagnosed with fibromyalgia and father dies of heart attack at the age of 40, grand father had an early death.

Investigations:

 the DHEAS level is high suggestive of pcod

bone deformities can suggest increased marrow production

genetic testing reveals seattle g6pd deficiency, AMPD1 deficiency,VWD type 1

given her history its evident that she is suffering from g6pd Deficiency which she didn't know until she got tested for it, most of the above problems could be linked to it i.e anemia, reaction to sulfa drugs, reaction to antimalarials and fave beans jaundice during birth

 The muscle weakness can be attributed to the Seattle type of G6PD Deficiency and I can also be due to AMPD1 Deficiency as her mother had a history of fibromyalgia

reference link
https://ghr.nlm.nih.gov/condition/adenosine-monophosphate-deaminase-deficiency#

The problem of pcod can be attributed to G6PD deficiency which can cause oxidative stress playing an important role in the pathophysiology on the problem

reference link
http://www.ijpvmjournal.net/article.asp?issn=2008-7802;year=2019;volume=10;issue=1;spage=86;epage=86;aulast=Mohammadi

The EKG revealed she had sinus tachycardia which is can be due to the stress and the left atrial enlargement can be due to increased left atrial pressure due to volume overload

The use of cimitidine explains the prolonged QT interval on the EKG

swelling can due to the excess salt intake and the decreased urine output suggests that her kidney are not functioning good as a result of oxidative stress and active loss of ions in urine as there is no ATP left for active transport and this explains salt cravings

The bruise on her left leg when fractured and heavy menstural bleeding can be explained because of VWD

The Treatment should be mainly concentrated on the limb weakness and swelling as she feels uncomfortable and can't do her daily chores normally and sleeplessness

L-serine is used for increasing the duration of sleep

cimetidine is used for rashes and decreasing androgens

G6pd deficiency treated with NAC and anemia with iron folate supplementation

AMPD1 deficiency can be treated with D-ribose which can probably help releave her muscle weakness

She should be advised not to take any medications or food that trigger haemolytic anemia due to G6PD deficiency and ask her not to stress the body by excercising a lot which may act as trigger
 ask her to stop or replace cimetidine as it may cause heart problems like torsedes de pointes due to prolonged QT interval