A 70 YEAR OLD MALE WITH COUGH AND ALTERED SENSORIUM.

General Medicine case discussion.

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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'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 comments in comment box are most welcomed 

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

Roll no 125

S.Neeraja Reddy 

A 70 year old male building supervisor by occupation presented with chief complaints of 

Cough  and SOB since 20 days

Fever since 3 days

Burning sensation in the oral cavity since 2days

History of present illness

Patient was apparently asymptomatic  20 days back when he developed cough followed by alcohol binge which was associated with sputum small quantity,non foul-smelling, non blood tinged.

He also complained of shortness of breath which was progressed from grade 2  to grade 4.

There is no history of orthopnea,paroxysmal 

nocturnal dyspnea.

Fever since  3 days not associated with chills and rigors resolved by medication.

He also complained of burning sensation in the oral cavity and was unable to take food and speak.

He went to local hospital for the above complaints and was treated symptomatically and was referred to our hospital as his condition was deteriorating.

On the day of presentation patient was in altered sensorium state drowsy  tachypbic but arousable

Past history 

There is no history of Diabetes Hypertension,coronary artery disease, Epilepsy, Asthma,Tuberculosis.

Personal history 

Takes Mixed diet

Normal  appetite

Bowel and bladder movements regular.

History of exposure to dust

Alcoholic since 30 years

No known allergies 

Family history 

Not significant 

General examination 

Patient was thoroughly examined after well informed consent. He is conscious coherent and coperative well oriented to time place and person 

No signs of Pallor Icterus cyanosis clubbing lymphadenopathy. 

VITALS:

PR: 87 bpm

BP: 120/70 mmHg

RR: 18 cpm

SpO2: 98%

Temperature: Afebrile 

Systemic examination 

Respiratory system 

INSPECTION 

shape of the chest  elliptical 

No drooping of shoulders

Supraclavicular hollowness

No visible pulsation or scars

No crowding of ribs

PALPATION

Inspection   findings are conformed

No tenderness 

No local rise of temperature 

PERCUSSION no dullness noted

AUSCULTATION 

CVS: S1, S2 heard, no murmurs

Abdominal examination:

Inspection: 

Shape of abdomen -scaphoid 

Position of Umbilicus- Central and inverted

All Quadrants of abdomen moving with respiration.

No visible scars and sinuses.

Hernial orifices free

No visible pulsations.

Palpation :

Soft

No tenderness

LIVER - Not Palpable

SPLEEN- Not Palpable

 Percussion :

NO SHIFTING DULLNESS

NO FLUID THRILL 

Bowel sounds heard.

CNS:  GCS: E4V4M6

Cranial nerve examination intact

Speech slurred 

Sensory system- sensitive to pain, touch , vibration and temperature.

Motor system             Right.      Left    

                    Power-     UL 5/5     5/5

                                      LL 5/5     5/5 

      Neck ,trunk power normal 

          Tone-     UL      Normal      Normal

                         LL       Normal     Normal 

          Reflexes- 

Superficial reflexes - Intact

Deep tendon reflexes -

                           Biceps    ++             ++

                           Triceps  ++            ++

                         Supinator  ++          ++

                                Knee  ++           ++ 

                             Ankle     ++          ++

      

                               Gait- Normal

                Cerebellar system - intact  

Investigations 

O.

Investigations on 7.1.2022

CBP : total  leucocyte count 13000 cells/cumm

APTT test : 57 second 

CUE : albumin + 

 Prothrombin time : 28 seconds 

FBS : 227 mg /dl 

Blood urea: 359mg/dl 

ABG : po2 198mmhg

           Pco2 19.9 mmhg

Serum Creatinine  5.5 mg/dl 

Uric acid 20.3 mg%

Sodium 161 mEq/L

Potassium  7.3 mEq/L

Chloride 117 mEq/L 

On 10.1.2022

Urea 127 mg/dl 

Creatinine 4.5 mg/dl 

Sodium  143 mEq/L 

Potassium  4.5 mEq/L 

Chloride 104 mEq/L 

Findings on 8/1/2022

 Prothrombin time 26 secs pro(longed

INR prolonged 

HEMOGRAM

Impression on smear 

RBC: NORMOCYTIC NORMOCHROMIC

WBC within normal limits

Platelets Adequate in number and distribution 

No hemiparasites

No monocytollgy

RFT urea 166 mg/dl

Creatinine 3.8 mg/dl

Uric acid 8.6mg%

Sodium 147 meq/l 

Potassium  4.5meq/l

Calcium, Chloride Potassium within normal range

Bacterial culture 

No growth after 24 hours of incubation

ULTRASOUND 

Increased echogenicity of kidney

Grade 1 fatty liver

Provisional diagnosis: altered sensorium secondary to uraemic encephalopathy, viral pneumonia with acute kidney injury secondary to sepsis.

Treatment 

Head end elevation

O2 inhalation 

Iv fluids NS RL DNS

Inj Lasix 40 mg iv/BD

Inj Piptaz 2.25gn Iv/TID 

Inj Thiamine 1Amp in 100 ml NSIv/TI D

Tab Montec- Lc peroral/od

Tab Pulmoclear po /od

Tab Ambroxyl 15ml Po / TID

Mucopain Gel LA BD

Betadine gargle

Bp/PR/ RR/ temperature 4th hely

GRBS 6th holy

Tab Azithromycin 500 mg Po /DO   OD

Nebulisation with Broad  spectrum of antibiotics.

After 1st session of dialysis no improvement 

Improved by 3rd session. 

4 sessions of hemodialysis done.