90Y MALE WITH RIGHT SIDED DEVIATION OF MOUTH

CBBLE UDHC SIMILAR CASES

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 .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

Patient was brought to casualty with complaints of deviation of mouth to right since yesterday morning,c/o slurring of speech since yesterday

HOPI: 

A 90Y/M who was a farmer by occupation (staying at home since 10-15Y) Patient was apparently asymptomatic 1 yr back. Patient c/o nocturia (10-12x) overnight and went to local hospital and diagnosed with DM-2  and since then he is on regular medication .Since yesterday patient woke  up from sleep. Patient complaints of deviation of mouth to right side and slurring of speech since yesterday.

Outside BP :190/100mmhg

No c/o involuntary micturition/defecation

No c/o involuntary movements

No c/o dysphagia 

No c/o UL/LL weakness noted

No c/o fever,cold,cough

No c/o  burning micturition since 1 month

No c/o sob, orthopnea

PAST HISTORY

k/c/o diabetes since 1 year and on regular medication since then

Not a k/c/o HTN/CAD/TB/BA 

No past surgical history 

PERSONAL HISTORY:

Married

Previously farmer

Appetite: Normal

BowelsBladder movements: Regular

 Addictions: 

Alcohol consumption (Occasional -90ml)

Had habit of smoking but stopped 5yrs ago

No other addictions

FAMILY HISTORY: Not significant

O/E :

Pt is c/c/c ,well oriented to time,place, person.

Pallor +

No signs of icterus, clubbing, cyanosis, lymphadenopathy, pedal edema.

Vitals: 

Temp: Afebrile

Pr: 62bpm

Rr:17cpm

Bp:160/90 mmhg

Spo2: 97% on ra

Grbs:129mg%

Systemic Examination:

Cvs:S1S2 heard, no murmurs heard

Rs: BAE+ ,NVBS heard

P/A: Soft, nontender

CNS:- 

pt conscious with Slurred speech

No signs of meningeal irritation 

                                        RIGHT               LEFT

1) TONE         UL        NORMAL       NORMAL

                         LL        NORMAL       NORMAL

2) POWER    UL          5/5                  5/5

                        LL           5/5                  5/5

3) HANDGRIP              100%

4) REFLEXES  

       a) BICEPS               +                    +

       b) TRICEPS            +                    + 

       c) SUPINATOR      +                    +

       d) KNEE                   +                    +

       e) ANKLE                -                     -

       f) PLANTAR        Mute             Mute

5) CEREBRAL SIGNS:

Finger nose coordination: +

Knee heel in coordination: +

Sensory system:- unable to examine

Investigations:-

HEMOGRAM

HB: 10.9

TLC: 4200

N/L/E/M/B:74/18/2/6/00 

PCV: 31.5

MCV: 95.3

MCH: 33.1

MCHC:34.7

RBC:3.31

PLT:1.74

RDW-CV :15.8

RDW-SD: 57.2

PS: NC/NC

BGT:- B POSITIVE

RFT:

BLOOD UREA :  30MG/DL

SERUM CREATININE: 1.1

URIC ACID:4.4

SERUM ELECTROLYTES:

Na+ : 139

K+: 2.7

Cl-: 99

LFT

TB: 1.19

DB: 0.28

SGOT:34

SGOT:10

ALP: 124

TP:5.8

ALBUMIN:3.81

A/G: 1.91

SEROLOGY: NEGATIVE

HBA1C : 6.8

FBS:141

PLBS: 94

CXR:-

ECG:-

2D ECHO:-https://youtu.be/XwX7t-Engh0

Imp:-

-Trivial TR+ ; no MR/AR

-No RWMA/No MS/AS ; sclerotic AV

-Good LV systolic function

-Diastolic dysfunction + ; No PAH/PE

MRI brain (16/2/22):-

Imp:-

-Acute Lacunar infarct in right corona radiata

-Old Lacunar infarcts in left thalamus and left corona radiata

-Chronic small vessel ischaemic changes

Carotid Doppler:(17/2/22):-

Provisional diagnosis:-

Acute ischemic CVA with UMN type of left facial palsy with acute infarct in right insular cortex.

Plan:-

1)Tab.clopotab 75mg po od

2)Tab.Ecospirin 75mg po od

3)Tab.atorvad 20mg po od

4)Inj.optineurin 1amp in 100ml Ns iv/od

-MRI Brain

65Y MALE WITH C/O WEAKNESS OF RIGHT UL&LL

CBBLE UDHC SIMILAR CASES

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 .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

A 65Y MALE WHO IS A DAILY WAGE LABOURER (SHEPHERD SINCE 10YRS) , CAME WITH COMPLAINTS OF WEAKNESS OF RIGHT UPPER LIMB AND LOWER LIMB SINCE 5 DAYS.

HOPI: 

PATIENT WAS APPARENTLY ASYMPTOMATIC 7YRS BACK.

 PATIENT HAD DINNER AROUND 8PM AND WENT TO SLEEP AROUND 2PM,HE WENT TO URINE AND SUDDENLY FELL IN BATHROOM, DIAGNOSED WITH RIGHT SIDED CVA AND ADVISED MEDICATION AND DISCHARGED.

IT TOOK AROUND 2-3 MONTHS TO WALK.NO SLURRING OF SPEECH AT THAT TIME,NO LOC.USED MEDICATION FOR 1YR AND STOPPED MEDICATION ON HIS OWN. RECOVERED APPROXIMATELY 75-80% (IN THEIR ATTENDERS LANGUAGE).

DIAGNOSED WITH HTN DURING ROUTINE CHECKUP AND STARTED ON ANTIHYPERTENSIVES BUT LATER STOPPED (AFTER 1 YR)

ONE WEEK BACK ,PT C/O UNABLE TO WAKEUP EARLY MORNING AFTER PASSING URINE.

C/O SLURRING OF SPEECH + , ABLE TO FEEL BLADDER FULL SENSATION.

C/O DYSPHAGIA +

C/O COUGH SINCE 3 DAYS.

NO C/O INVOLUNTARY DEFECATION 

NO C/O CHEST PAIN, SOB, PALPITATIONS.

PAST H/O : 

K/C/O HTN SINCE 1 YEAR WAS ON MEDICATION BUT STOPPED LATER

NOT A KNOWN CASE OF DM, BA, TB, CAD.

PERSONAL HISTORY:

DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , PASSED STOOLS 3 DAYS BACK

BLADDER MOVEMENTS - ABNORMAL

HABIT OF ALCOHOL CONSUMPTION (OCCASIONAL)

NO OTHER ADDICTIONS

NO KNOWN DRUG ALLERGIES

FAMILY HISTORY: NOT SIGNIFICANT

ON EXAMINATION 

PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE

NO SIGNS OF PALLOR ,ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, PEDAL EDEMA.

VITALS: 

TEMP: 98.6°F

PR: 100 BPM

BP:110/80 MMHG

SPO2: 94% ON RA

GRBS: 83mg%

SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS HEARD

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD

PER ABDOMEN: 

SHAPE OF THE ABDOMEN : OBESE 

SOFT, NONTENDER, NO ORGANOMEGALY 

CNS:

 

 PATIENT IS CONSCIOUS WITH SLURRED SPEECH 

 NO NECK STIFFNESS ,

                           - RIGHT            LEFT

1) TONE UL NORMAL             NORMAL                                         LL NORMAL             NORMAL

2) POWER UL 4/5                  4/5

                      LL 3/5                  4/5

3) HANDGRIP 100%

4) REFLEXES  

       a) BICEPS    3+.                    2+

       b) TRICEPS 3+.                    2+ 

       c) SUPINATOR 3+               2+

       d) KNEE       2+.                     1+

       e) ANKLE       -                       -

       f) PLANTAR extensor          flexor

INVESTIGATIONS:

HEMOGRAM: 

HB: 15.4

TLC: 8,700

N/L/E/M/B: 78/12/02/08/00

PCV: 43.7

MCV: 37.8

MCH: 30.9

MCHC:35.2

RBC:4.98

PT:2.18

RDW-CV :13

RDW-SD: 42.5

PS: NC/NC

RFT:

BLOOD UREA : 22 MG/DL

SERUM CREATININE: 1.1

SERUM ELECTROLYTES:

Na+ : 135

K+: 4.1

Cl-: 98

LFT

TB: 2.11

DB: 0.94

SGOT:41

SGOT:26

ALP: 98

TP:7.4

ALBUMIN:3.83

A/G: 1.07

SEROLOGY: NEGATIVE

HBA1C : 6.5%

PLBS: 108mg/dl

SER.LIPID PROFILE: 

Total cholesterol: 196mg/dl

Triglycerides: 157mg/dl

HDL: 1.03

LDL:94

VLDL:31

TFT(10/2/22):

T3:1.03

T4;14.97

TSH:1.45

ECG: 

CXR

Repeat CXR(11/2/22):

2D ECHO: https://youtu.be/qDuJHzFoJAw

TRIVIAL TR+ / MR + / MILD ARD

GOOD RV& LV SYSTOLIC FUNCTION + 

NO RVMA , MIXED LVH + ,NO PAH

MINIMAL PE+ ; DIASTOLIC DYSFUNCTION + 

CT BRAIN: (DONE OUTSIDE ON 5/2/22)

IMP: 

ILL DEFINED PATCHY HYPODENSITY IN LEFT BODY OF CAUDATE NUCLEUS AND LEFT CORONA RADIATA-? SUBACUTE TO CHRONIC INFARCT

CHRONIC LACUNAR INFARCTS IN BILATERAL CAPUSLOGANGLIONIC REGIONS AND BILATERAL CORONA RADIATA

DIFFUSE CEREBRAL ATROPHY

CHRONIC SMALL VESSEL ISCHEMIC CHANGES

USG ABD AND PELVIS:(10/2/22)

NO SONOLOGICAL ABNORMALITY DETECTED

COLOR DOPPLER(10/2/22)

MRI BRAIN(11/2/22):

IMP:-

-Acute infarcts in right caudate nucleus,putamen, internal capsule and adjacent corona radiata.

-Mild diffuse cerebral and cerebellar atrophy with small vessel ischaemic changes.

TREATMENT PLAN

T.CLOPITAB   75MG PO/OD

T.ECOSPIRIN 75MG PO/OD

T.ATORVAS     20MG PO/OD

T.PAN 40 MG PO/OD

                           SOAP NOTES

DAY 1:

AMC BED 2

S: Patient c/o cough

O: 

Pt c/c/c 

Temp:- 98.6°F

PR 86

SPO2 97%

GRBS 87mg%

BP 130/80mmhg

CVS: S1S2 HEARD

RS: BAE+

P/A: SOFT,NONTENDER

CNS                  RIGHT.                 LEFT     

POWER      

     UL.               3/5                    3/5

     LL                4/5                    4/5

TONE     

       UL.           . increased       normal

        LL.             increased      normal

4) REFLEXES  

  a) BICEPS   3+                    2+

  b) TRICEPS 3+                   2+ 

  c) SUPINATOR 3+             2+

  d) KNEE       3+                   2+

  e) ANKLE.         -                  -

  f) PLANTAR extensor   flexor

A: Subacute R sided CVA with Subacute infarct in L CAUDATE nucleus & L corona RADIATA with hypertension

P : 

T. Clopitab 75mg 

T. Ecospirin 75mg

T. Atorvas 20mg 

T. Pan 40 mg  

T. Monteleukast

Syp.Ascoril

Planned for 2decho and Color Doppler

DAY 2:

S: Patient c/o cough

O: 

Pt c/c/c 

Temp:-98.8°F

PR 92

SPO2 98%

GRBS 94mg%

BP 140/90mmhg

CVS: S1S2 HEARD

RS: BAE+

P/A: SOFT,NONTENDER

CNS               RIGHT         LEFT     

 POWER      

     UL              3/5                3/5

     LL              4/5                 4/5

TONE     

     UL.             increased       normal

      LL.             increased.     normal

REFLEXES  

  a) BICEPS.       3+                   2+

  b) TRICEPS    3+                    2+ 

  c) SUPINATOR 3+                 2+

  d) KNEE.           3+                  2+

  e) ANKLE          -                     -

  f) PLANTAR extensor          flexor

A: Subacute R sided CVA with Subacute infarct in L caudate nucleus & L corona radiata with hypertension

P : 

T. Clopitab 75mg 

T. Ecospirin 75mg

T. Atorvas 20mg 

T. Pan 40 mg 

T. Monteleukast

Inj.optineuron 

Inj.Augmentin

Syp.Ascoril

Planned for MRI BRAIN, repeat cxr

DAY 3:-

S:Patient c/o cough, one fever spike yesterday night

O: 

Pt c/c/c 

Temp:97°F

PR 85bpm

SPO2 96%

GRBS 170mg%

BP 150/90mmhg

CVS: S1S2 HEARD

RS: BAE+

P/A: SOFT,NONTENDER

CNS               RIGHT          LEFT     

 POWER      

     UL.              3/5                 3/5

     LL                4/5                 4/5

TONE     

     UL.         increased       normal

      LL.        increased        normal

REFLEXES  

  a) BICEPS.      . 3+             2+

  b) TRICEPS      3+             2+ 

  c) SUPINATOR 3+            2+

  d) KNEE.             3+          2+

  e) ANKLE           -              -

  f) PLANTAR extensor    flexor

A: Subacute R sided CVA with Subacute infarct in L caudate nucleus & L corona radiata with hypertension

P : 

T. Clopitab 75mg po od 

T. Ecospirin 75mg po od

T. Atorvas 20mg po od

T. Pan 40 mg po od

T. Monteleukast po od

T.Amlong 5mg po od

T.Pcm 500mg po qid

Inj.optineuron 1ampin100ml/ns/od

Inj.Augmentin 1.2mg/iv/tid

Syp.Ascoril 5ml po tid 

Monitor Temp/Bp/grbs 4th hrly

Planned for Fundoscopy

65Y OLD WITH ALTERED SENSORIUM

CBBLE UDHC SIMILAR CASES

65Y OLD WITH ALTERED SENSORIUM

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 .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

PATIENT CAME WITH C/O ALTERED SENSORIUM SINCE 5AM (2/2/22), SOB GRADE IV SINCE TODAY MORNING. 

HOPI: 

PATIENT WAS APPARENTLY ASYMPTOMATIC 20Y BACK, PATIENT WENTTO REGULAR CHECKUP AND CAME TO DIAGNOSE WITH DM-II.

18 YRS BACK HE HAD H/O TRAUMA ON LEFT LITTLE TOE AND DUE TO  CELLULITIS ,LEFT LITTLE TOE HAS BEEN AMPUTATED.

SIX YRS BACK PATIENT AGAIN DEVELOPED LEFT LL CELLULITIS FOR WHICH FASCIOTOMY HAS BEEN DONE, SINCE THEN INSULIN HAS BEEN STARTED,MIXED INSULIN (30/70)35U -x-30U ,

LINAGLIPTIN 2.5MG/MF- 500MG AS DOCTORS MENTIONED  RAISE OF CREATININE. (NO REPORTS AVAILABLE).

DAPAGLIFOZIN 10 MG WAS ADDED.

NO C/O CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND.

C/O BURNING MICTURITION SINCE 2 DAYS.

H/O COVID-19 20 DAYS BACK

PAST HISTORY: 

KNOWN CASE OF DM SINCE 20 YRS.

NOT A KNOWN CASE OF HTN, BA, TB, CAD.

PERSONAL HISTORY:

DIET - MIXED,

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , PASSED STOOLS YESTERDAY

BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

NO KNOWN DRUG ALLERGIES

FAMILY HISTORY: NOT SIGNIFICANT

TREATMENT HISTORY: 

Inj.25D IV/STAT 

PATIENT IS CURRENTLY ON

T.CLINIDIPINE 10MG/PO/BD

ON EXAMINATION 

PATIENT HAS ALTERED SENSORIUM

SIGNS OF  PALLOR +, PEDAL EDEMA + 

NO ICTERUS, CYANOSIS, CLUBBING OF FINGERS.

VITALS: 

PR: 110 BPM

BP:180/80 MMHG

SPO2: 94% ON RA

GRBS: 33MG%-->225 MG%

SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS HEARD

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD

PER ABDOMEN: 

SHAPE OF THE ABDOMEN : OBESE 

SOFT, NONTENDER, NO ORGANOMEGALY 

CNS: PATIENT WAS DROWSY INITIALLY WITH SLURRED SPEECH 

 INVESTIGATIONS:

RAT : NEGATIVE

RTPCR : NEGATIVE

SEROLOGY:NEGATIVE

HEMOGRAM: 

HB: 14.5

TLC: 9.600

N/L/E/M/B: 94/03/01/02/00

PCV: 42.1

MCV: 85.4

MCH: 29.4

MCHC:34.4

RBC:4.93

PT:1.30

RDW-CV :13.6

RDW-SD: 43.2

PS: NC/NC IMP: ABSOLUTE NEUTROPHILIA WITH MILD THROMBOCYTOPENIA

RFT:

BLOOD UREA : 46 MG/DL

SERUM CREATININE: 1.9

SERUM ELECTROLYTES:

Na+ : 138

K+: 5.7

Cl-: 103

LFT

TB: 0.96

DB: 0.22

SGOT:49

SGOT:40

ALP:206

TP:6.3

ALBUMIN:3.8

A/G: 1.53

 USG: IMP: B/L GRADE-1 RPD

ECG: 

CXR: 

PROVISIONAL DIAGNOSIS: 

HYPOGLYCEMIA SECONDARY TO OHA.

TREATMENT PLAN:

T.CLINIDIPINE 10MG/PO/BD

SOAP NOTES 

DAY 1: 

AMC BED 1 

S : Sensorium improved 

      No SOB

O :

O/E 

No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema

Temp : Afebrile

PR : 88 bpm

RR : 22 cpm

BP : 150/100 mmhg

Spo2 : 98 % at RA

CVS : S1 S2 + , No murmurs 

RS : bae + , clear

PA : soft, non tender GRBS :

 8 AM : 285 - 12 HAI

10 AM : 121

 2 PM : 324 - 16 HAI

 4 PM : 229

 8 PM : 225 - 14 HAI

10 PM : 324

 2 AM : 202

 8 AM : 225 

 A:HYPOGLYCEMIA SECONDARY TO ? OHA/ ? INSULIN WITH CKD SINCE 6 MONTHS AND DM SINCE 18 YEARS 

P : 

1. IVF NS 100ML/HR

2. INJ HAI SC/TID

     acc to sliding scale

3. INJ. NPH SC/BD

4. GRBS CHARTING

5. TAB. CILNIDIPINE 10 MG/PO/OD 

6. TAB. M6T XL 50 MG/PO/OD 7. BP/PR/TEMP/RR CHARTING 4TH HRLY

DOA:3

AMC BED 2

S : Sensorium improved 

      No SOB

O :

O/E 

No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema

Temp : Afebrile

PR : 82 bpm

RR : 19 cpm

BP : 150/90 mmhg

Spo2 : 98 % at RA

CVS : S1 S2 + , No murmurs 

RS : BAE + , clear

PA : soft, non tender    

 GRBS :

 8 AM : 225 - 12 HAI+10R

10 AM : 224

 2 PM : 142 - 10R

 4 PM : 225

 8 PM : 145 - 12N +10R

10 PM : 190

 2 AM : 62 -25D 

 8 AM : 109 10N+10R

A:HYPOGLYCEMIA SECONDARY TO ? OHA WITH AKI ON CKD WITH HTN AND DM.

P : 

1. IVF NS 100ML/HR

2. INJ HAI SC/TID

     acc to sliding scale

3. INJ. NPH SC/BD

4. GRBS CHARTING

5. TAB. CILNIDIPINE 10 MG/PO/BD 

6. TAB. MET XL 50 MG/PO/OD 7. BP/PR/TEMP/RR CHARTING 4TH HRLY

DOA: 4

AMC BED 2

S : Sensorium improved 

      No SOB

      C/o 1 hypoglycemic episode at 2AM 

     No fever spikes

O :

O/E 

No pallor/icterus/cyanosis/clubbing/ generalized lymphadenopathy/ pedal edema

Temp : Afebrile

PR : 88 bpm

RR : 23cpm

BP : 140/70 mmhg

Spo2 : 98 % at RA

CVS : S1 S2 + , No murmurs 

RS : BAE + , clear

PA : soft, non tender    

 GRBS :

 8 AM : 225 - 12 HAI+10R

10 AM : 224

 2  PM :  142  -  10R

 4  PM :  225

 8  PM :  145  -  12N +10R

10 PM :  190

 2  AM :  62 -25D 

 8  AM :  109 10N+10R

 A:HYPOGLYCEMIA SECONDARY TO ? OHA WITH AKI ON CKD WITH HTN AND DM SINCE.

P : 

1. IVF NS 100ML/HR

2. INJ  HAI SC/TID

     acc to  sliding scale

3. INJ. NPH  SC/BD

4. GRBS CHARTING

5. TAB. CILNIDIPINE 10 MG/PO/BD 

6. TAB. MET XL 50 MG/PO/OD                                           7. BP/PR/TEMP/RR CHARTING 4TH HRLY

-PLAN TO DISCHARGE

ADVICE AT DISCHARGE

INJ HAI SC/TID    12-8-10

INJ. NPH SC/BD   10-X-10

TAB. CILNIDIPINE 10 MG/PO/BD

TAB.MET XL 50 MG/PO/OD

TAB.METHYLCOBALAMIN 1000MCG PO/OD

33Y/F WITH ARTHRALGIA

 

CBBLE UDHC SIMILAR CASES

 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 .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

33 year old female came with the chief complaints of :

Arthralgia since 2 months 

Fever since 5 days 

Vomitings and loose stools since 4 days 

Abscess over the right thigh (?ruptured) since 5 days .

HOPI :

Patient was apparently asymptomatic 2 months ago then she developed fever which is of low grade associated with polyarthralgia lasted for 15 days for which she used Tab . Paracetamol , Tab.Diclofenac after which the patient still didn't get any relief 

There's no effect of her symptoms on her daily activities and her occupation.

The patient took COVID vaccine 

H/o small and large joint pains with swelling around the joints 

Due to the persistence of fever and polyarthralgia the patient visited rheumatologist in the month of October (RF -Normal ,HB - 9 g/dl , ESR -110 )

There the patient was advised :

1.Tab .HCQ 200 mg OD for 2 weeks (8pm)

2.Tab.Prednisolone 20 mg OD for 2 weeks (8am)

3.Tab.Azathioprine 50 mg OD in the morning for 2 weeks 

After using these medicines her symptoms got subsided

Today patient has come to our hospital with fever which is of high grade associated with chills and rigors , vomitings - non bilious ,non projectile , food and water as the content , stools - watery in consistency ,large volume mucous , no blood in stools 

No h/o Malena ,hematuria 

Past history :

Not a k/c/o diabetes mellitus , hypertension, asthma ,cad , tuberculosis 

Past surgical history :

Tubectomy done 10 years ago 

Personal history :

Diet -mixed 

Appetite - decreased since 2 months 

Bowel habits - regular 

Bladder habits - urgency present 

Sleep - adequate 

No addictions 

Family history : 

Patient's mother is a known case of diabetes and hypertension since 10 years 

Obstetric history :

Age of marriage - 18

P2L2 

General examination : 

Patient is conscious, coherent,cooperative ,thin built and poorly nourished 

Mild pallor present 

No cyanosis , icterus , clubbing,lymphadenopathy , edema

Mild dehydration present 

Vitals :

Pulse rate - 88 bpm 

Temperature- 100°F

RR - 12 cpm 

BP - 80/50 mmHg 

Systemic examination : 

CVS : S1 S2 + , no added murmurs 

RS :BAE + ,NVBS heard 

CNS : no focal neurological deficits 

P/A :soft , non tender 

        No organomegaly 

        No distension 

        Bowel sounds heard

Local examination of the abscess : 

1 x 1 cm wound present over the anterior aspect of left thigh with surrounding erythema .

Local rise of temperature +

Tenderness +

No pus discharge 

(Diagnosis given by the surgery dept for the abscess - Ruptured sebaceous cyst ) 

Advice given for the abscess :

1.Tab CHYMEROL forte -TID 

2.Tab Hifenac -P PO /BD 

3.Tab Vit -C PO /OD 

4.Regular dressings

Investigations sent on the day patient got admitted : 

1.ECG 

2.USG abdomen - no sonological abnormality detected 

3.RFT : urea - 20 mg/dl , creatinine - 0.7 mg/dl ,Na+ - 146 meq/L , K+ - 4.2 meq/L , Cl- 105 meq/L 

4.LFT : TB - 1.21 , DB - 0.26 , AST - 26 , ALT - 10 , ALP - 95 , TP - 5.9 , Albumin - 3.2 , A/G ratio - 1.22 

5.Hemogram : HB - 8.5 g/dl , TLC - 1,300 , N/L/E/M - 61/27/2/10 , PLt - 1.19 , RBC - 2.90

PCV - 24.1 , MCV - 83.1 , MCH - 29.3 

6.ESR - 85 mm 

7.CUE : Sugar , albumin - nil , pus cells - 3 to 4

E.cells - 2 to 3 

8.Malarial parasite - negative 

9.Chest x-ray 

Previous investigations of the patient :

HB - 9.5 g/dl 

TLC - 2,900

PCV - 28.1 

PLt - 1.89 

K+ - 2.8 

HB - 9 g/dl 

TLC - 4,900 

PLt - 2.69 

R factor - normal 

CRP - 9 

ESR - 10 

Alb - 3.9

TSH - 7.16 micro IU/ml 

USG - free fluid in the pelvis 

Provisional diagnosis :

Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation.

Treatment given : 

1.IVF - NS , RL @ 100 ml/hr 

2.Inj Optinneuron 1 amp in 100 ml NS IV/OD 

3.Inj Neomol 1 gm IV SOS (if temp >=101 degree Fahrenheit)

4.Inj Pantop 40 mg IV OD 

5.Inj Zofer 4 mg IV TID 

6.Inj Ceftriaxone 1 gm IV BD 

7.Tab Sporolac -DS PO TID 

8.Tab Dolo 650 mg PO TID 

9. Tab Baclofen 12.5 mg PO SOS ( if hiccups persist )

10.ORS sachets in 1 litre of water - 100 ml /stool. 

11.Tab Redotil 100 mg PO /BD 

Diagnosis : Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation with pancytopenia 

Investigations : 

1.Reticulocyte count - 0.5

2.Absolute reticulocyte count - 0.3

3.RI - 0.1 (Hypoproliferative marrow ) 

4.T3 - 0.86 

5.T4 - 10.04 

6.TSH - 7.38

7.Spot protein creatinine ratio - 0.75 

                             SOAP NOTES

AMC bed  1 

S- No fever spikes 

No nausea/vomitings 

O - pt is c/c/c 

Afebrile 

PR-86 bpm

BP - 110/70 mmHg

RR - 20 cpm

SPO2 - 96 % at RA 

CVS - S1 S2 +

CNS - NAD 

RS - BAE + 

P/A - soft , non tender

I/O - 3200/1950 ml

GRBS - 89 mg/dl 

A - Acute gastroenteritis (Resolved ) with ruptured sebaceous cyst with pancytopenia under evaluation 

P- 1.IVF - NS and RL @ 75 ml/hr 

2.Plenty of oral fluids 

3.Inj pantop 40 mg IV OD 

4.inj Zofer 4 mg IV SOS 

5.inj Ceftriaxone 1 gm IV BD

6.tab dolo 650 mg po sos 

7.tab Sporolac -DS po sos 

8.thrombophore ointment for l/a 

9.I/O and temperature charting