Internal Assessment June 2023

 

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

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

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.

38 year old female came to casualty with chief complaints of pain abdomen flanks radiating to front since 4 days fever since four days lower backache since 4 days 

History of presenting illness:

Patient was asymptomatic 20 years back when she develop fever and weakness. She went to a nearby hospital. She was known to be a diabetic at the age of 18 years. She continued the medications of oral hypoglycemic agents. 2 years back she developed pain in abdomen and fever. They suspected pylonephritis. She had a similar episodes for 3 to 4 times and treated conservatively. One year back she again had flank pain and abdominal pain. On investigation they got to know that there is uncontrolled blood sugar for which they gave insulin. After sometime they switched to oral hypoglycemic agents on discharge. She stopped working at the dairy she used to, since a year. 

Patient had sudden weight loss one year ago. 

Patient developed fever 4 days back with high grade fever not associated with cough cold, loose tools, shortness of breath and vomiting 

Pain (squeezing) in the flank radiating to the abdomen increases during micturition relieved after the urination

Lower back pain radiating to the front not associated with burning micturition

Patient has been vomiting once daily since 2 days

History of past illness: 

She is a k/c/o DM and on medications tab metformin, glimeperide, volibox

N/k/c/o asthma, TB, Epilepsy, HTN, CAD

Personal history:

mixed diet

loss of appetite since a week 

bowel and bladder movements are normal 

inadequate sleep due to lower back pain. wakes up at midnight to urinate. 

Family history:

mother is diabetic. 

On Examination :Patient is conscious, coherent, cooperative and well oriented to time, place and person

Vitals: 

BP- 130/70 mm of Hg

PR- 64 beats per minute

RR- 22 per minute

Temperature- afebrile

Grbs 

CVS examination :

S1 S2 heard

Apex beat is medial to mid clavicular line 

No palpable thrills and murmar no thrills bilateral 

 

Respiratory system examination:

Bilateral airway entry is present

Wheeze and crepts are absent 

P/A :

Tenderness present on left iliac and lumbar region

Supra pubic and renal angle tenderness  

INVESTIGATIONS 

3/10/22

S

B/l flank pain lt>rt radiating to front, fever 

O 

Vitals 150/90

PR 68 

Temp 97.7

RR 16

Grbs 238

 spo2 98

 A 

 Acute lt pyelonephritis 

 P 

 IVF ns rl @75ml / hr 

 Inj piptaz 4.25 MG IV tid 

 Inj diclo 1amp IV sos 

 Inj hai s/c ACC grbs 

 Grbs monitoring

4-10-22

S: pain in the left flank

1 episode of vomiting 

O:

BP-130/90mmHg

PR-68bpm

RR- 22cpm

Spo2-98@ RA

Temp - 98.7

CVS-S1 S2 +

RS-BAE+

CNS-NFND

A:LT. ACUTE PYELONEPHRITIS 

P:

IVF NS RL @75ML/HR 

INJ. PIPTAZ 4.25 MG/IV/TID(DAY6)

INJ. TRAMADOL 1AMP IN 100 ML NS TID

TAB. ULTRACET PO/ 1/2 TAB /QID (DAY2 W/H)

(1/2-1/2-1/2-1/2)

INJ. HAI S/C ACC TO GRBS INFORM 

GRBS CHARTING

MONITOR VITALS INFORM SOS

 

5/10/22

S

B/l flank pain lt>rt radiating to front fever 

O 

Vitals 130/90

PR 68 

Temp 97.7

RR 16

Grbs 238

 spo2 98

 A 

 Acute lt pyelonephritis - emphysematous 

 P 

 IVF ns rl @75ml / hr 

 Inj piptaz 4.25 MG IV tid 

 Inj Tramadol 1amp in 100ml ns tid 

 Tab ultra cet po 1/2 tab qid 

 Inj hai s/c ACC grbs 

 Grbs monitoring

Internal Assessment (General Medicine)

 

Answer sheet is uploaded in reverse fashion.

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

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

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.

A 44 year old male patient came to the hospital with chief complaints of fever with chills and rigor, shortness of breath, epigastric pain since 20 days and back pain on the left side since 10 days

HISTORY OF PRESENTING ILLNESS: 

The patient was asymptomatic 15 years back and had history of intake of alcohol initially 90 ml which gradually progressed to daily intake of 300 ml of alcohol with no or minimal food intake. The patient developed high grade fever with chills and rigor. He was admitted to a hospital outside for a month and was treated as alcoholic liver disease with Total Bilirubin 23.7 gradually reduced to 2.5. The patient developed epigastric pain since past 20 days and back pain on the right side since 10 days.

Patient has decreased appetite and an episode of vomiting.

High grade fever with chills and rigor on and off

SOB on exertion 

Pain in abdomen in left lumbar region, dragging type of pain 

HISTORY OF PAST ILLNESS:

The patient was admitted to a hospital 4 years back with complaints of fever and was treated within 3 days.

N/K/H/O Diabetes, HTN, Asthma, TB, Epilepsy; 

PERSONAL HISTORY:

Divorcee 

Loss of appetite 

Normal bowel movement (1 to 2 times per day)

Normal micturition (4 to 5 times per day)

Disturbed sleep due to pain since 20 days 

Alcohol intake since 15 years 

Tobacco chewing since 15 years (1 pack every 2 days)

PSYCHIATRIC HISTORY:

The patient tried to commit suicide 7 years back by intake of pesticide. 

FAMILY HISTORY:

N/K/C/O DM, HTN, Epilepsy, TB, asthma; 

GENERAL EXAMINATION:

No pallor

icterus present - yellowish discolouration of sclera

No cyanosis 

No clubbing of fingers 

No lymphadenopathy

VITALS:

Temperature- febrile

Pulse rate- 135 bpm

BP- 90/60 mm Hg 

SpO2- 98%

GRBS- 85 mg/dl 

SYSTEMIC EXAMINATION:

CVS:

S1, S2 heard, no murmurs

RESPIRATORY SYSTEM:

BAE +

P/A: obese, splenomegaly, no tenderness 

CNS:

No abnormalities detected;

Glasgow scale- 15/15 

PROVISIONAL DIAGNOSIS:

Alcoholic Liver Disease with alcohol dependence 

INVESTIGATIONS:

CBC:

USG 

5.2 mm calculus noted at lower pole of right kidney 

USG findings: Gross hepatomegaly,

Emphysematous pyelonephritis

TREATMENT:

1) IVF NS @ 5 ML /HR  ,RL,5 %D 

2) INJ PANTOP 40.MG IV/OD 

3)INJ ZOFER 4 MG IV/SOS 

4) INJ NEOMOL 100 ML NS IV / SOS (IF TEMP GREATER 101 F ) 

5) TAB PCM 500 MG.PO/TID 

6) I/O CHARTING 

7) TEMP CHARTING 

8) GRBS 6 TH HOURLY 

9) SYP LACTULOSE 15 ML PO/HS

10) INJ TRAMADOL 1 AMP IN 100 ML NS IV/BD 

11) VITALS 2ND HOURLY

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

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

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.

CASE SCENARIO:

A 53 year old male patient came to the hospital for Dialysis 

History of Presenting Illness:

The patient was asymptomatic 4 years ago. 3 years back the patient went to a medical practitioner with complaints of shortness of breath and fatigue, malaise, loss of appetite and fatigue. Patient was diagnosed with kidney failure on one side. The patient was given medication to sustain kidney failure. The patient continued his medication for kidney failure which he eventually stopped after a year. 

One month back, the patient went to a hospital with chief complaints of headache, fever and pedal oedema. He was admitted there and was diagnosed with CKD. He underwent 4 dialysis procedures there. The patient came to the hospital and underwent further 9 dialysis till date. 

History of Past Illness:

3 years back, the patient was diagnosed with Tuberculosis and was given drug therapy (ATT) for 6 months. He was cured. One month back the patient was again diagnosed with recurrent Tuberculosis and drug therapy is being given. 

1 year ago, the patient met with a bike accident. Since then, the patient claims to have neck stiffness. 

Patient has a history of HTN since one month. 

Personal History:

• married
• mixed diet 
• loss of appetite since the past month 
• discomfort in sleeping since 2 days 
• Patient had a history of alcohol intake. He used to drink half a bottle everyday and then stopped taking alcohol 3 years ago. He drinks it occasionally now. 
• Patient had a history of smoking 2 to 3 cigarettes per day which he stopped 3 years ago. 

Family History: Not significant 

Treatment history:

For reactive TB, a combination therapy with isoniazid, rifampin, pyrazinamide and ethambutol is being given. 

General Examination:

Pallor -

Icterus -

Clubbing -

Cyanosis - 

Lymphadenopathy -

Edema - pedal edema seen until the ankle 

Vitals:

PR: 96 bpm

BP: 130/90 

SpO2: 97%

RR: 40 

Systemic Examination:

 

CVS:

The chest wall is bilaterally symmetrical 

S1, S2 heard ; no murmurs 

CNS:

Patient is conscious, coherent and cooperative

R/S: 

Central position of trachea 

Bilateral crests are heard in all areas 

https://youtu.be/584IkrZ1XR4

 PROVISIONAL DIAGNOSIS: CKD on Hemodialysis 

GENERAL MEDICINE SEPTEMBER 2021 BIMONTHLY BLENDED ASSIGNMENT

 I, Vanshika Savla, a 3rd sem student of 2k19 batch have been given this assessment on general medicine.

QUESTION 1 :

(Testing peer review competency in the active reader of this assignment) 

Please go through the case reports in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

QUESTION 2 :

Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data):

Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. 

QUESTION 3 :

Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

QUESTION 4 :

Testing competency in patient data capture and representation through ethical case reporting/case presentation with informed consent :

QUESTION 5 :

Testing scholarship competency in  

logging reflective observations on your concrete experiences of this last month :

Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research.