This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
Mentioned here are my learning points, both theoretical and practical surrounding this patient:
-Taking psychosocial and past history of this patient was particularly eye opening. She had several hospital admissions in the last 2 years with 3 for pyelonephritis alone. Her history made me realize the hardships of patients with chronic health conditions, and the pain that both her and her family would have to suffer from it.
-I also got to learn the pathophysiology of PAH and how to causes murmurs. Additionally, I got to appreciate the murmurs in this patient as well.
-An interesting medical dilemma surrounding this patient was whether or not to give IV fluids. 2D ECHO showed a collapsing IVC along with cardiac failure.
A 50 year old female came to the OPD with chief complaints of :
-Fever since 1 week
-Left loin pain since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 12 years ago when she had an episode of giddiness. She went to the doctor for the same and was diagnosed with Type II DM. Since then, she has been on insulin ever since, and has been using it regularly.
In August 2021, she went to a physician again with complaints of fever and joint pains, wherein she was diagnosed with typhoid and treated for the same.
In October 2021, she had burning micturition and abdominal pain for 5 days, following which she went to the doctor. She was started on Tab. Nitrofurantoin.
In March 2022, she developed a fever, with nausea, decreased appetite and body pains since 10 days. She was diagnosed with Uncontrolled Type II DM with sepsis and pyelonephritis and admitted for the same until the pyelonephritis resolved.
In July 2022, she started having left loin pain along with abdominal pain, and a low grade fever with chills. She had also had 2 episodes of vomiting. She was admitted, and diagnosed with Diabetic Ketoacidosis with Recurrent Pyelonephritis.
In December 2022- she developed an ulcer over her left foot following an RTA (bike vs car), which later developed into an abscess. The abscess was drained, and the ulcer was left to heal.
In May 2023, she became drowsy and unresponsive, associated with sweating. Her GRBS was found to be 28mg/dl, and she was diagnosed with a hypoglycemic episode.
Since 3 months, the patient has had neck pain, radiating to both her upper limbs, and back. The pain is persistent, with no aggravating or relieving factors as such. Due to the pain, she has restriction of neck movements.
1 week ago, she developed fever which was high grade, intermittent type and associated with chills and rigors. It was relieved on taking medication (Tab DOLO). There was no diurnal variation.
She also had left loin pain since 1 week, which was intermittent and dragging type, radiating towards the back, and was also relieved on taking medication.
Additionally, she had two episodes of vomiting 1 week ago, which was non projectile and non bilious, and contained food particles.
No history of burning micturition, decreased urinary output, facial puffiness
No history of cough, cold, rash, loose stools
Due to these complaints, she came to the OPD and was advised admission based on her symptoms and previous history. She was not willing to be admitted that day due to her daughters being busy, and was admitted 5 days later.
PAST HISTORY
As mentioned, she has had similar complaints in the past.
She had a hysterectomy with bilateral salpingo-oophorectomy 14 years ago
No history of HTN, CVD, CAD, thyroid, TB, asthma, epilepsy
PERSONAL HISTORY:
Diet - vegetarian
Sleep - Disturbed since 3-4 months
Appetite - Decreased since 3-4 months
Bowel and bladder - regular
No addictions
No allergies
PSYCHOSOCIAL HISTORY:
Patient is 50 years old
She studied till 7th grade, after which she started involving herself in household work. She got married at 15 years, after which she was a housewife, and took care of all the household chores.
Before her diabetes diagnosis, she used to eat most foods. However, since her diagnosis, she has mostly been eating bajra and limited her consumption of rice.
Since having diabetes, she used to wake up at 5am, finish her chores and have 1-2 rotis at 9am. She would have lunch at 1pm, which was usually bajra mixed with water. Then she would continue her household chores and have dinner at 9pm, which was also usually bajra. She would sleep by 10pm.
She is a vegetarian and hence does not consume meat.
Since 6 months, she has not been able to do any of her chores at home. She has mostly been restricted to her bed, and gets tired when she works for even short periods of time. Additionally due to her neck pain she has been having difficulty in doing normal activities also.
She feels that her disease has been a burden on her due to the constant hospital visits and the amount of money spent, ie, around 5 lakhs on treatment alone.
FAMILY HISTORY:
No significant history
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
She is moderately built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
Pedal edema- Absent
Pallor noted
Vitals :
Temperature - 96.8 ° F
Blood Pressure -130/70 mmHg
Pulse Rate -78 bpm
Respiratory Rate - 13 cpm
RBS - 158 gm/dl
SYSTEMIC EXAMINATION:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
PALPATION-
Abdomen soft
No local rise of temperature
Tenderness present over left lumbar region
Inspectors findings are confirmed
No palpable masses
Liver is not palpable
Spleen is not palpable
PERCUSSION:
Resonance note heard over all quadrants
AUSCULTATION:
Bowel sounds heard
CVS EXAMINATION:
INSPECTION
The chest wall is bilaterally symmetrical
JVP raised in supine position, not raised on sitting/ standing
No dilated veins, scars or sinuses are seen
Apical impulse not visible
Video showing raised JVP in supine position
PALPATION:
Apex beat diffuse
AUSCULTATION:
S1 and S2 heard
Murmurs heard over tricuspid and pulmonic region
RS EXAMINATION:
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Vocal resonance: resonant in all areas
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
PROVISIONAL DIAGNOSIS:
HEART FAILURE SECONDARY TO HIGH OUTPUT FAILURE SECONDARY TO ANEMIA SECONDARY TO SEVERE PAH TYPE 2
DIABETIC NEPHROPATHY AND RETINOPATHY
IRON DEFICIENCY ANEMIA SECONDARY TO ?NUTRITIONAL ?ANEMIA OF CHRONIC DISEASE
DE NOVO HYPERTENSION
B/L ACUTE PYELONEPHRITIS
LEFT FOOT DIABETIC ULCER (RESOLVING)
ACUTE KIDNEY INJURY ON CKD (STAGE 4)
EVALUATION:
Investigations done on 20/6/23:
Hemogram:
Hb: 6.7gm%
TLC: 9700
PCV: 20.4
MCV: 76.7
MCHC: 32.8
RBCs: 2.66lakhs/cumm
PLT: 1.96
LFT
TB: 0.62
DB: 0.20
AST: 15
ALT: 12
ALP: 377
TP: 5.5
Albumin: 3.0
RFT
Urea- 117
Creatinine- 5.7
Na: 130
K: 4.3
Cl: 98
CUE
Albumin +
Pus cells: 3-4
RBCs: NIL
FBS: 197 mg/dl
PLBS: 348 mg/dl
HBA1C: 6.5
Serum Osmolarity: 300.7
Urinary electrolytes:
Na: 142
K: 8.3
Cl: 115
24 hours urinary creatinine: 0.8g/day
24 hour urinary protein 720mg/day
22/6/23:
RFT
Urea: 108
Creatinine: 2.5
Na: 136
K: 4.1
Cl: 103
23/6/23:
RFT
Urea: 107
Creatinine: 4.5
Na: 132
K: 3.9
Cl: 98
24/6/23:
RFT
Urea: 100
Creatinine: 4.2
Na: 136
K: 4
Cl: 98
Updated fever chart:
USG abdomen:
Xray KUB:
ECG:
2DECHO:
2DECHO Report:
Xray SPINE:
ABG:
CXR- PA:
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