A 52 yr old female ,homemaker by occupation

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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”


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 : 



CASE : 

A 52 year old female,house wife  resident of narketpally came to the causality in a drowsy state
She was apparently asymptomatic 1 week back,when she sustained an injury to the left LL(shin according to attenders but wound not visible outside -outside  x-rays normal ),after which she developed pain and edema ,she was treated outside with pain killers ,had restricted movements and hence did not move much and lied on bed most of the time ,walked with support and gradually the swelling got decreased to some extent . 5 days later she again visited RMP as her appetite was decreased and also associated with generalised weaknesses  and left lower limb pain and also hip( localisation not possible )for which pt was given  IV fluids and pain killers.
This morning after eating ,she had sudden onset of around 10-15 vomiting episodes with nausea then she suddenly became drowsy ,while she was being shifted here,there is irrelevant talk and pt was incoherent.

On presentation, pt was unconscious with 
E1V1M4 to E1V1M1



Past history : 

No H/o diabetes, hypertension,asthma epilepsy,TB 
No similar complaints in the past 
No history of any surgeries or blood transfusions



Personal history : 


Diet - Veg 
Appetite - decreased 
Sleep - adequate
Bowel and bladder movements : Regular 
No known allergies
No history of alcohol consumption or smoking

On examination: 

Pt is stupourous ,withdrawal from pain 
Febrile to touch:100°F
PR: 86bpm
BP: 130/70 mmHg
RR: 24

CVS: S1, S2 heard

RS: BAE present ,end inspiratory wheeze in all areas ,
Spo2: 96%on room air

P/A: obese ,non tender ,bowel sounds sluggish 

CNS: 

Pupils - right side -NS RL 
Left side - post cataract surgery r/n to light 
Gag present
Tone : normal b/l
Reflexes
       Lt. Rt
B. 2+. 2+
T. 2+. 2+
S. 2+. 2+
K 2 +. 2+
A. 2+. 2+
P. Upgoing. Upgoing


Provisional diagnosis:

Altered sensorium under evaluation secondary to hyponatremia( euvolemia)?SIADH 
Sepsis secondary to ?cellulitis ? Typhoid
with complete right bundle branch block 


Investigations : 




RFT : 

Urea - 15 
Creatinine - 0.6 
Uric acid - 2
Calcium - 8.6
Phosphorus - 3.2
Na+ : 118 
K+ : 3.8 
Cl- : 76 

LFT : 

TB : 0.88
DB : 0.20
AST : 26
ALT : 13
ALP : 177 
TP : 5.5 
ALB : 3.1
A/G : 1.33 



Serum osmolality :


Serum sodium @ 10pm 


Urinary electrolytes : 



ECG : 







CHEST X RAY : 


MRI BRAIN : 



TREATMENT : 

1) Propped up position 
2) IVF 3% Nacl @10 ml/hr 
3) Ryles catheterization 
4)Foley's catheterization 
5)Inj.Piptaz 4.5 gm /IV/BD
6) RT feeds : 100ml water 2nd HRLY 
                        50 ml milk 4rth HRLY 




Day 2 of admission : 

Pt is stupourous ,withdrawal from pain 


Febrile to touch:100°F
PR: 86bpm
BP: 130/70 mmHg
RR: 24


CVS: S1, S2 heard

RS: BAE present ,end inspiratory wheeze in all areas ,
Spo2: 96%on room air

P/A: obese ,non tender ,bowel sounds sluggish 

CNS: 

Pupils - right side -NS RL 
Left side - post cataract surgery r/n to light 
Gag present
Tone : normal b/l
Reflexes
       Lt. Rt
B. 2+. 2+
T. 2+. 2+
S. 2+. 2+
K 2 +. 2+
A. 2+. 2+
P. Upgoing. Upgoing


Diagnosis:

Altered sensorium under evaluation secondary to hyponatremia( euvolemia)?SIADH 
Sepsis secondary to ?cellulitis ? Typhoid
with complete right bundle branch block 


Investigations : 

RFT : 

Urea - 13
Creatinine - 0.6 
Uric acid - 2
Calcium - 8.5
Phosphorus - 3.5
Na+ : 128 
K+ : 3.9
Cl- : 90


ABG : 

 
Electrolytes @ 2pm : 

Na+ : 123
K+ : 3.9 
Cl- : 85 
  


Electrolytes @10 pm : 

Na+ : 123
K+ : 3.9 
Cl- : 85 


Pt developed bed sore on her right 
buttock : 





Treatment : 


1) Propped up position 
2) IVF 3% Nacl @10 ml/hr 
3) Inj.PANTOP 40 mg PO/OD
4)Inj.Piptaz 4.5 gm /IV/TID
5) Nebulization with budecort @ 8th HRLY and 
                                    Asthalin @12th HRLY 
6) RT feeds : 100ml water 2nd HRLY 
                        50 ml milk 4rth HRLY 


Day 3 of admission : 

Still in altered sensorium 
And attendant complaints of her having on and off fever episodes and no improvement in sensorium since admission 
O - 
However her GCS has gone up from E1M1V1 to E2V1M1 
RR - 35 cpm 
PR - 124bpm
BP- 120/70mmhg
Temp - 101 F
Spo2 - 98%on 15L RA
CNS -
E2M1V1
Pupils - 
Bilaterally reacting to light 
Left post cataract surgery 
Hypotonia + in all 4 limbs 
Reflexes- 
Bilateral biceps +
Plantars - Mute 
Corneal and conjunctival reflexes +
No meningeal signs 

Lungs - Bilateral inspiratory crepts in all Lung fields
And expiration wheeze in all Lung fields

Cvs - S1,S2+
Per Abdomen - soft
Bowel sounds +

A -
Altered senorium secondary to ? Hyponatremia 
Sepsis secondary to ? cellulitis 
? Typhoid
With complete RBBB 

P - 
LP was done will be updating shortly
Continuing her on 
Inj 3% NACL @ 10ml/hour 
Inj Pantop 40mg IV OD
Inj Piptaz 4.5 gm/IV/TID
Neb with budecort 8th hourly and Asthalin 12 hourly 
RT feeds - 100ml milk and 50ml free water 2nd hourly 
Tab Dolo 650mg sos 



Hemogram : 

Hb - 11.6
TLC : 46500 
Plt : 39900
RBC : 4.56 


ABG @ 6am : 


Chest xray : 


ECG : 


 
ABG @ 12pm : 


After lp,csf was sent for analysis : 

Volume : 1ml
Appearance : clear 
Color : slightly reddish 
TC - 436 (corrected WBC count ) 
Dc - 90% neutrophils ,10% lymphocytes
RBC - 14650
Others : nil


Awaiting cytology reports

Csf sugar : 25 
Csf protein : 29 
Csf chloride : 116
RBS : 85




Electrolytes @6pm : 

Na - 122
K - 4.2
Cl - 80 


Day 4 :

52 year old woman, 
ICU bed 1
Still in altered sensorium 
And attendant complaints of her having on and off fever episodes 
 no improvement in sensorium since admission 
O - 
 GCS E2V1M1 
Pt is on mechanical ventilation 
Simv - vc mode 
Tv - 400 ml
PEEP - 5 cm of h20 
FiO2 - 30%
RR - 40 cpm 
PR - 94bpm
BP- 110/60mmhg
Temp - 37.3 C
Spo2 - 98%on 15L RA
CNS -
E2M1V1
Pupils - 
Bilaterally reacting to light 
Left post cataract surgery 
Hypotonia + in all 4 limbs 
Reflexes- 
Bilateral biceps +
Plantars - Mute 
Corneal and conjunctival reflexes +
No meningeal signs 

Lungs - Bilateral inspiratory crepts in all Lung fields
And expiration wheeze in all Lung fields

Cvs - S1,S2+
Per Abdomen - soft
Bowel sounds +

A -
Altered senorium secondary to ? Hyponatremia 
Sepsis secondary to ? cellulitis ? Pyogenic meningitis
? Typhoid
With complete RBBB 

P -
Inj.Dexa 4mg iv/ bd
Inj. Ceftriaxone 2 gm iv. Bd
Inj Pantop 40mg IV OD
RT feeds - 100ml milk and 50ml free water 2nd hourly

Investigations : 

Hb - 11 
TLC - 52500
Pcv - 29.2
Plt - 3.48 

TB - 3.46 
Db - 0.63 
AST - 1036 
Alt - 530 
TP - 5.3
Alb - 2.73 
A/g - 1.06 

ABG : 

pH - 7.527 
pCo2 - 13.7 
PO2 - 106 
HCo3 - 17.4 

Rft : 

Urea - 137
Creat - 2.8
uric acid - 11.5 
Ca- 10.2 
Phosphate - 11.2 
Na - 119 
K - 4.3 
Cl - 75 



Lft trends in this patient : 



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