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46 year old male patient with burning micturition, vomitings and giddiness



General Medicine E-LOG Book 

Final practical examination: Long case

M. Sri Nithya 

Hall ticket no: 1701006101

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.


This E-log also reflects my patient centered online learning portfolio.


I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.

LONG CASE

A 46 year old male patient came to casuality with chief complaints of :

-burning micturition since 10days

-vomiting since 2days (3-4 episodes)

-giddiness and drowsiness since 1day.


History of presenting illness:

Patient was apparently asymptomatic 10 days back then he developed burning micturition, it was not associated with fever or decrease in urine output. There is no increase in urgency or frequency of micturition.

 He also complained of vomiting since 2 days. The vomitus is non- projectile,non bilious,non foul smelling(3-4 episodes),containing food particles.

later he complained of giddiness and drowsiness for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.

No history of fever/cough/cold 

No significant history of UTIs

Past history:

10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back

3years back OHAs were converted into Insulin

3years back he underwent cataract surgery

1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.

Delayed wound healing was present- it took 2months to heal

Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid

Not on any medication

No history of blood transfusion 


Personal history:

Appetite- normal

Diet - Mixed

Bowel and bladder- Regular, burning micturition present

Sleep- Adequate 

Habits/Addiction:

Alcohol-

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off  consumption pattern previously present 

Family history:

Not significant


General Examination:

Patient was examined in a well lit room with informed consent.

Patient is conscious, coherent, co-operative, well oriented to time, place and person. 

Pallor- present

 


No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No dehydration.


Vitals @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 99F

SpO2: 98% on RA

GRBS: 124 mg/dL







SYSTEMIC EXAMINATION: 
ABDOMEN EXAMINATION
INSPECTION:
Shape – elliptical
Flanks – full
Umbilicus –everted
All quadrants of abdomen are moving with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
Apical Impulse is not appreciated 
 Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion of liver for liver span
Percussion of spleen- dull note 
AUSCULTATION:
Bowel sounds are feeble.
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses. 
Apical impulse and pulsations cannot be appreciated. 
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.


PALPATION:


Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 


PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.


CENTRAL NERVOUS SYSTEM EXAMINATION.

Higher mental functions test: 

Pt is having altered sensorium 

Slurred speech 

Not Orientated to time place person.

Memory couldn't be elicited as pt is in altered sensorium 

Cranial nerves : intact 

Motor system :   

1, Bulk : right. Left 

Upper limb normal. Normal

Lower limb. thigh -N. Normal

 Below knee amputated on R side


2, Tone : 

Upper limb. Normal. Normal 

Lower limb. Normal. Normal 


3.Power :

Neck:. Normal 

Trunk:. Normal

Upper limb 5 5

Lower limb 5 5 


 4, Reflexes 


             Right Left 

Biceps 2+. 2+

Triceps 2+ 2+

Supinator. 2+ 2+

Knee 2+. 2+

   Ankle 2+. 2+       

Planter reflex Amputated flexion

Sensory system : normal 

Meningeal signs : negative


Investigations:

On admission (19.5.22)



X ray KUB


CT Scan



Liver function tests:


Renal function tests:



Ultrasound report abdomen and pelvis

20.05.22

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

Culture report:  Klebsiella Pneumonia positive




Pus cells

21.5.22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.2.22



25.5.22



27.5.22

Hb- 7gm%

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

Provisional Diagnosis: 

Right emphysematous pyelonephiritis and left acute pyelonephiritis, encephalopathy secondary to sepsis. 

H/o of Type 2 Diabetes mellitus since 10years

Treatment:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

Day 11:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000











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