general medicine posting case 2
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 diagnosis and treatment plan
Ch.preethi
Admission number:176050
75 year old women came to causality on 10/01/23 with
C/o SOB since last night
cough since 15days
Fever since yesterday evening
K/C/O cellulitis - surgery done 20 days back
HOPI:
Patient was apparently asymptomatic 3 years ago and then developed minor abrasion to right lower limb and then developed right lower limb swelling till knee and was diagnosed to be having right lower limb cellulitis and fasciotomy was done and resolved after 2 months and at the time dm was diagnosed and kept on medication.she was normal from then and 20 days back she developed sudden swelling of left lower limb till knee intially and then progressed to thigh.she went to local hospital and found to have left lower limb cellulitis and on further evaluation found to be having erosion of knee and was diagnosed septic arthritis and incision and drainage was done and left knee osteotomy was done , fasciotomy and debridement of left lower limb was done.20 pRBC'S transfusions was done and daily dressing was done.since 5 days she developed fever which was incidious in onset,high grade,with chills and rigor.she developed SOB since 3 days and also was on altered sensorium since 3 days.
No urine output since yesterday night for which Foleys catheter was placed today morning and she is passing urine now.
PAST HISTORY:
K/C/O DMT2 on Tab zorylmv1(metformin 500 mg +glimeperide 1mg+ voglibose 0.2mg) since 3 years.
Not a K/C/O HTN/asthma/TB/Epilepsy/CAD/CVA/Thyroid disorders.
MENSTRUAL HISTORY:
Age of menarche: 13 years
Age of menopause: 50 years
PERSONAL HISTORY:
Appetite: normal.
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no addictions
GENERAL EXAMINATION:
Patient is drowsy but arousable.
Pallor: present
Icterus:abesnt
Cyanosis:absent
Clubbing: absent
Lympadenopathy:absent
Edema:absent
VITALS:
Temp: 97.7F
Bp:120/70mmhg
PR:90bpm
RR:16cpm
Spo2:97
GRBS:211mg/dl
SYSTEMIC EXAMINATION:
Respiratory- B/L air entry present; diffuse wheeze present
CVS- s1s2+ no murmur
P/A soft non tender
CNS- patient is drowsy
PERSONAL HISTORY:
Appetite: normal.
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no addictions
INVESTIGATIONS:
Diagnosis:
Altered sensorium decrease evaluation meningoencephalitis secondary to left lower limb cellulitis with ? Septic arthritis in left knee.
k/c/o DMT2
P
1. Iv fluids NS and RL @ 75ml/hr
2.inj.Mnocef 2gm iv/bd
3. Inj. Pan 40mg IV/OD
4. Inj. Noemal 1gm/IV/SOS
5.Inj. Zofer 4mg/IV/OD
6.inj.optineuron 1amp in 10ml NS/IV/OD
7.syrup.Ascoryl- /RT/BD
8.RT feeds - 50ml milk 4th hourly
100ml water 2nd hourly
9.NEB with Budecort and Duolin 6th hourly
10.left lower limb elevation
11.Grbs monitoring 70 profile
ON 13th January
S
Pt c/o shortness of breath
Fever subsided
Productive cough with expectoration 15days
Stools passed
O
Patient is concious coherent oriented to person and place not oriented to time
Temp-97.7F
BP-130/70mmhg
PR-120bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ; diffuse wheeze present
CNS- patient is drowsy
GCS-E2V2M4
P/A-soft and non tender
Hb-8.2
TLC-17800
RBC-2.9million
Pcv24.8
S urea:74
S Cr:1.5
Na-135
K-3.8
Cl-98
Ica-0.70
TB-0.80
DB-0.19
AST-20
ALT-10
ALP-307
T.pro-6.5
Alb-2.0
A/G-0.45
FBS-163
PLBS-351
HBA1C-7.5
R.C-2.3
Absolute reticulocyte -1.4
Ret.index:0.68
A
Altered sensorium (resolving) secondary to focal encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with anemina under evaluation
Right heart failure secondary toCOPD
With s/p: left nee aspiration on 10/12/23and lumbar puncture on 11/12/23
P
1.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
2.inj.meropenem 500mg/iv/BD
3.inj.vancomycin 1gm/iv/BD
4. Inj. Pan 40mg IV/OD
5.Inj. Zofer 4mg/IV/OD
6.inj.human Actrapid insulin/SC/TID
7.inj.vitK 1amp in 100mlNS/IV
8.inj Lasix 20 mg/IV/BD
8.Dolo 650mg /RT/TID
7.syrup.Ascoryl-LS /RT/TID
9.NEB with Budecort and Duolin 6th hourly
10.left lower limb cellulitis
11.Grbs monitoring 70 profile
12.bp temp monitoring 2nd hrly
ON 14th January
S
Fever
Pt c/o shortness of breath
Productive cough with expectoration 15days
Stools passed yesterday
O
Patient is drowsy but aerosable oriented to person not oriented to time and place
Temp-98.4F
BP-130/70mmhg
PR-106bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ;crepts are absent
CNS- patient is drowsy
GCS-E4V4M5
P/A-soft and non tender
GRBS:
12am- 191
8am-249mg/dl
S urea:56
S Cr:0.8
Na-140
K-3.1
Cl-101
Ica-0.86
A
Altered sensorium (resolving) secondary to focal encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with anemina under evaluation
Right heart failure secondary toCOPD
With acute kidney injury(?prerenal)
left knee aspiration on 10/12/23and lumbar puncture on 11/12/23.
P
1.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
2.inj.meropenem 500mg/iv/BD
3.inj.vancomycin 1gm/iv/BD
4. Inj. Pan 40mg IV/OD
5.Inj. Zofer 4mg/IV/OD
6.inj.Human Actrapid insulin s/c /TID
10U-10U-10U
8am -1pm-8pm
7.inj.vitK 1amp in 100mlNS/IV
8.inj Lasix 20 mg/IV/BD
9.Dolo 650mg /RT/TID
10.Tab mct-xl 12.5 RT/OD
10.syrup.Ascoryl-LS /RT/TID
11.NEB with Budecort and Duolin 6th hourly
12.left lower limb cellulitis
13.Grbs monitoring 70 profile
14.bp temp monitoring 2nd hrly
On 15th January
Date : 15/01/23
ICU bed no. 2
S
Fever subsided
Pt c/o shortness of breath
Stools passed today
O
Patient is drowsy but arosable
Patient is not oriented to place person and time.
Temp-98.6F
BP-130/80mmhg
PR-118bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ;crepts are absent
CNS- patient is aerosable but confused
GCS-E4V2M5
P/A-soft and non tender
GRBS:
8am-103mg/dl
8pm-249mg/dl
2am-203mg/dl
Hb-9.5
TC-22700
Urea: 36
Creatinine:0.9
A
Altered sensorium (resolving) secondary to septic encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with
Right heart failure secondary toCOPD with anemina under evaluation with grade 1 bedsore
left knee aspiration on 10/12/23
lumbar puncture on 11/12/23.
Wedge biopsy on 13/12/23
P
1. Iv fluids NS RL with 1amp optineuron @50ml/hr.
2.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
3.inj.meropenem 500mg/iv/BD
4.inj.vancomycin 1gm/iv/bd in 100ml NS over 45min.
5. Inj. Pan 40mg IV/OD
6.Inj. Zofer 4mg/IV/OD
7.inj.Human Actrapid insulin s/c /TID
10U-10U-10U
8am -1pm-8pm
8.inj.NPH/SC/BD
8am-8pm
6U-6U.
9.inj Lasix 40 mg/IV/BD
10.MET XL 12.5 mg/RT/OD
11.Tab.Olanzapine 2.5mg sos (8pm)
12..syrup.Ascoryl-LS /RT/TID
13.NEB with Budecort and Mucomist 6th hourly
14.left lower limb dressing and elevation
12.Grbs 7 ponit profile
13..bp temp monitoring 2nd hrly
14.Tab Orofer-XT/RT/OD
ON 16th January
Date : 16/01/23
S
Fever subsided
Pt c/o shortness of breath
Stools passed yesterday
O
Patient is oriented to place and person but not oriented to time.
Temp-98.4F
BP-130/70mmhg
PR-98bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ;crepts are absent
CNS- patient is aerosable but confused
GCS-E4V4M5
P/A-soft and non tender
GRBS:
8am-103mg/dl
7pm-327mg/dl
2am-310mg/dl
8am-319mg/dl
Hb-8.7
TC-18700
RBC-3.06millio
A
Altered sensorium (resolving) secondary to septic encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with
Right heart failure secondary toCOPD with anemina under evaluation with grade 1 bedsore
left knee aspiration on 10/12/23
lumbar puncture on 11/12/23.
Wedge biopsy on 13/12/23
P
1. Iv fluids NS RL with 1amp optineuron @50ml/hr.
2.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
3.inj.meropenem 500mg/iv/BD
4.inj.vancomycin 1gm/iv/bd in 100ml NS over 45min.
5. Inj. Pan 40mg IV/OD
6.Inj. Zofer 4mg/IV/OD
7.inj.Human Actrapid insulin s/c /TID
10U-10U-10U
8am -1pm-8pm
8.inj.NPH/SC/BD
8am-8pm
6U-6U.
9.inj Lasix 40 mg/IV/BD
10.MET XL 12.5 mg/RT/OD
11.Tab.Olanzapine 2.5mg/RT/TID
12..syrup.Ascoryl-LS /RT/TID
13.NEB with Budecort and Mucomist 6th hourly
14.left lower limb dressing and elevation
12.Grbs 7 ponit profile
13..bp temp monitoring 2nd hrly
14.Tab Orofer-XT/RT/OD
Date : 17/01/23
S
Fever
Pt c/o shortness of breath
Stools passed yesterday
O
Patient is drowsy but arosable
Patient is oriented to place person and but not oriented to time.
Temp-98.6F
BP-110/70mmhg
PR-98bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ;crepts are absent
CNS- patient is aerosable but confused
GCS-E4V2M5
P/A-soft and non tender
GRBS:
8am-319mg/dl
10am-229mg/dl
12pm-261mg/dl
8pm-131mg/dl
10pm-172mg/dl
2am-158mg/dl
8am-220mg/dl
Hb-10.4
TLC-18100
Pc-6.5
PT-17
APTT-35
INR-1.25
A
Altered sensorium (resolving) secondary to septic encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with
Right heart failure secondary toCOPD (?cor pulmonale) with anemina under evaluation with grade 1 bedsore
left knee aspiration on 10/12/23
lumbar puncture on 11/12/23.
Wedge biopsy on 13/12/23
P
1. Iv fluids NS RL with 1amp optineuron @50ml/hr.
2.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
3.inj.meropenem 500mg/iv/BD
4.inj.vancomycin 1gm/iv/bd in 100ml NS over 45min.
5. Inj. Pan 40mg IV/OD
6.Inj. Zofer 4mg/IV/OD
7.inj.Human Actrapid insulin s/c /TID
14U-14U-14U
8am -1pm-8pm
8.inj.NPH/SC/BD
8am-8pm
6U-6U.
9.inj Lasix 40 mg/IV/BD
10.MET XL 12.5 mg/RT/OD
11.Tab.Olanzapine 2.5mg sos (8pm)
12..syrup.Ascoryl-LS /RT/TID
13.NEB with Budecort and Mucomist 6th hourly
14.left lower limb dressing and elevation
12.Grbs 7 ponit profile
13..bp temp monitoring 2nd hrly
14.Tab Orofer-XT/RT/OD
15.NEOSPORIN /T BACT ointment for L/A
16. Physiotherapy at left lower limb (knee Rom)
17.mobilise the patient
Date : 19/01/23
AMC bed no. 3
S
Pt c/o shortness of breath
Stools passed yesterday
O
Patient is drowsy but arosable
Patient is oriented to place and but not oriented to time and person.
Temp-98.6F
BP-120/70mmhg
PR-90bpm
CVS- s1s2 heard ; no murmurs
RS-b/L air entry present ;mild crepts are present.wheeze absent
CNS- patient is aerosable but confused
GCS-E4V6M6
P/A-soft and non tender
GRBS:
8am-177mg/dl
10am-147mg/dl
12pm-247mg/dl
8pm-74mg/dl
10pm-121mg/dl
2am-31mg/dl
8am-62mg/dl
Hb-9.8gm/dl
TLC-2400cells/cumm
Plt-8.06lakhs/cumm
RBC-3.54million/cumm
A
Diagnosis:
Altered sensorium (resolving) secondary to septic encephalopathy secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with
Right heart failure secondary toCOPD (?cor pulmonale) with anemina under evaluation with grade 1 bedsore
left knee aspiration on 10/12/23
lumbar puncture on 11/12/23.
Wedge biopsy on 13/12/23
P
1. Iv fluids NS RL @100ml/hr.
2.inj.vancomycin 1gm/iv/bd in 100ml NS over 45min.
3. Inj. Pantoprazole 40mg IV/OD
4.inj.Ondansetron 4mg/IV/OD
5.Tab metformin 500 mg/PO/BD
6.Tab.Metoprolol succinate 12.5 mg/PO/OD
7.Tab.Olanzapine 2.5mg PO/sos .
8.Tab.Glimiperide 1000mg+Tab.Metformin 500mg/PO/BD
9.Tab.ferrous Ascorbate+Folic acid PO/OD
10.syrup.Ambroxol+Levosalbutamol 10ml /PO/TID
11.syrp.Aristrozyme 30ml/PO/TID(20mins before food)
12.NEB with Acetylcysteine 6th hourly and Budesonide 12th hrly
13.left lower limb dressing and elevation
14.oint.Neomycin+polymyxin-B for L.A
15.bp temp monitoring 2nd hrly
16. Physiotherapy at left lower limb (knee Rom)
17.mobilise the patient
18.plenty of oral fluids
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