IMMANI AASRITHA
3rd sem, roll num:49
under the guidance of Dr. Rishik (Intern)
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have 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 SCENARIO:
A 52yr old patient came to the ward on 29 June 2021 with chief complaints of right lower limb swelling, intermittent fever (alive and well), shortness of breath since 3days, and burning micturition for 15 days.
HISTORY OF PRESENTING ILLNESS
The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee.
No H/O trauma, thorn prick, nausea, vomiting
c/o a small wound, watery discharge since 2 days
Fever- 5days intermittent, low grade, a/w chill
A light rise in temp
sob on exertion -5days
a/w cough- 1yr non-productive
Burning micturition- yesterday
No feeling 0f pain or discomfort in the body
HISTORY OF PAST ILLNESS
Not a k/c/o DM, HTN, Asthama, Epilepsy, TB
TREATMENT HISTORY
No usage of drugs as of now
PERSONAL HISTORY
Married
Occupation: fishing
A non-vegetarian, mixed diet
Micturition-burning micturition
Alcohol- occasional
Tobacco smoking
FAMILY HISTORY
No H/O same complaints in the family
GENERAL EXAMINATIONS
NO-Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition/Dehydration
Temperature- afebrile C/F
Pulse rate- 116/min
Respiration rate- 22/min
BP- 140/90 mm/Hg
SPO2- 92%
GRBS- 90mg%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
RESPIRATORY SYSTEM
Dyspnoea - Yes
No Wheezing
Position of Trachea - Central
Adventitious Sounds - Rales
ABDOMEN
Shape - Obese
No tenderness, palpable mass, No fluid, No bruits, No bowel sounds
Hernial Orifices - Normal
Liver Spleen - Not palpable
Genitals speculum examination, PV examination, P/R examination - Normal
CENTRAL NERVOUS SYSTEM
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
ENT
Flexible laryngo-pharyngoscopy is done
Nasal cavity- bilateral inferior turbinate hypertrophy- present
Nasopharynx- enlarged torus tuberous bilaterally
Velopharynx- circumferential collapse seen
Soft palate and uvula and lateral pharyngeal band- collapsing causing the circumferential collapse
Large- tongue base (grade: 2-3)
epiglottis- collapse seen on respiration
FINDINGS IN MULLERS MANEUVER
Grade 3 to grade 4 circumferential collapse
Seen at valopharynx and oropharynx region
INVESTIGATIONS
|
ELECTROCARDIOGRAM |
RENAL FUNCTION TESTS on 2nd July 
|
RANDOM BLOOD SUGAR on 29th June |
 |
RENAL FUNCTION TEST on 29th June |
|
COLOUR DOPPLER 2D ECHO on 30th June |
|
HEMOGRAM on 29th June |
|
COMPLETE URINE EXAMINATION on 29th June |
|
ARTERIAL BLOOD GAS on 2nd July |
|
COMPLETE BLOOD PICTURE on 2nd July 
sleep study 
|
LARYNGOPHARYNGO SCOPY
PROVISIONAL DIAGNOSIS:
Right lower limb cellulitis
Right heart failure 2nd degree to COPD
AKI 2nd degree to cellulitis - resolved
DM-II
Heart failure with a preserved ejection fraction (HFPEF)
TREATMENT
IVF- 10RL@ 75ml/hr,
10DNS conclusion 1amp of optineurin
Injection- MAGNEXFORTE 1.5gm/IV/TID
- METROGYL 100 microlitre/IV/TID
- LASIX 40 mg/IV/TID
8am ---- 2pm ---- 8pm
Tablet- Pantop Homg/PO/OD
NeB with Budecort/IN/BD
Ipravent/IN/TID
Tablet- Chymoral Forte/PO/TID
MgSO4 + Glycerol dressings
PR/BP/RR/SPO2 charting 2nd hourly
Strict IO charting
GRBS charting 6th hourly - PPBS
10pm ---- 4pm ---- 8pm ----2am
Tablet- TELMA 40 mg PO/OD
8am---- X ---- X
DISCHARGE SUMMARY:
Expected discharge date: 07/06/2021
Treating faculty:
Dr. Rakesh Biswas (HOD)
Dr. Hareen (SR)
Dr. A.Vaishnavi (PGY2)
Dr. K. Mansa (PGY1)
Dr. Rishik (Intern)
Dr. Vittal (Intern)
Dr. B. Roopa (Intern)
Dr. Ch.Dheekshitha (Intern)
Dr. G. Preethi (Intern)
DIAGNOSIS:
Right lower limb cellulitis
Right heart failure 2nd degree to COPDAKI 2nd degree to cellulitis - resolved
DM-II
Heart failure with a preserved ejection fraction (HFPEF)
CASE SCENARIO:
A 52yr old patient came to the ward on 29 June 2021 with chief complaints of right lower limb swelling, intermittent fever (alive and well), shortness of breath since 3days, and burning micturition for 15 days.
HISTORY OF PRESENTING ILLNESS
The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee.
No H/O trauma, thorn prick, nausea, vomiting
c/o a small wound, watery discharge since 2 days
Fever- 5days intermittent, low grade, a/w chill
A light rise in temp
sob on exertion -5days
a/w cough- 1yr non-productive
Burning micturition- yesterday
No feeling of pain and discomfort in the body
HISTORY OF PAST ILLNESS
Not a k/c/o DM, HTN, Asthama, Epilepsy, TB
TREATMENT HISTORY
No usage of drugs as of now
PERSONAL HISTORY
Married
Occupation: fishing
A non-vegetarian, mixed diet
Micturition-burning micturition
Alcohol- occasional
Tobacco smoking
FAMILY HISTORY
No H/O same complaints in the family
GENERAL EXAMINATIONS
NO-Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition/Dehydration
Temperature- afebrile C/F
Pulse rate- 116/min
Respiration rate- 22/min
BP- 140/90 mm/Hg
SPO2- 92%
GRBS- 90mg%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
RESPIRATORY SYSTEM
Dyspnoea - Yes
No Wheezing
Position of Trachea - Central
Adventitious Sounds - Rales
ABDOMEN
Shape - Obese
No tenderness, palpable mass, No fluid, No bruits, No bowel sounds
Hernial Orifices - Normal
Liver Spleen - Not palpable
Genitals speculum examination, PV examination, P/R examination - Normal
CENTRAL NERVOUS SYSTEM
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
ENT
Flexible laryngo-pharyngoscopy is done
Nasal cavity- bilateral inferior turbinate hypertrophy- present
Nasopharynx- enlarged torus tuberous bilaterally
Velopharynx- circumferential collapse seen
Soft palate and uvula and lateral pharyngeal band- collapsing causing the circumferential collapse
Large- tongue base (grade: 2-3)
epiglottis- collapse seen on respiration
FINDINGS IN MULLERS MANEUVER
Grade 3 to grade 4 circumferential collapse
Seen at valopharynx and oropharynx region
TREATMENT:
IVF- 10RL@ 75ml/hr,
10DNS conclusion 1amp of optineurin
Injection- MAGNEXFORTE 1.5gm/IV/TID
- METROGYL 100 microlitre/IV/TID
- LASIX 40 mg/IV/TID
8am ---- 2pm ---- 8pm
Tablet- Pantop Homg/PO/OD
NeB with Budecort/IN/BD
Ipravent/IN/TID
Tablet- Chymoral Forte/PO/TID
MgSO4 + Glycerol dressings
PR/BP/RR/SPO2 charting 2nd hourly
Strict IO charting
GRBS charting 6th hourly - PPBS
10pm ---- 4pm ---- 8pm ----2am
Tablet- TELMA 40 mg PO/OD
8am---- X ---- X
ADVICE AT DISCHARGE
Tab.GLIMI-MI /PO/OD - 8am-x-x
Tab.Metformin 500mg /PO/OD - 2pm
Tab.TELMA 40mg PO/OD (8am)
Tab.CHYMEROL FORTE PO/TID -2days
(R) LL evaluation
FOLLOW UP
Review after 3 weeks for fasting blood sugar (FBS) and (PLBS) Post prandial blood sugar.
----------THANK YOU----------
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