General Medicine Internship Real Patient OSCEs Towards Optimizing Clinical Complexity
General Medicine Internship Real Patient OSCEs Towards Optimizing Clinical Complexity
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 evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 diagnosis and treatment plan.
C/o abdominal distension, Abdominal bloating sensation since 20days
Bilateral Pedal edema since 6months
History of presenting illness:
Patient was apparently alright 6 months back then developed bilateral pedal edema, which was insidious in onset gradually progressive pitting type extending upto knee
Abdominal distension which was insidious in onset gradually associated with sob and loss of appetite No chest pain,
No h/o chest pain, sweating, palpitations ,orthopnea,PND
No H/O burning micturition
No H/O fever,cold,cough
No H/O nausea, vomiting, loose stools
Past history
k/c/o diabetes 2 since 10 years
K/c/o CAD s/p PTCA done on 17/8/22
K/C/O CKD , CLD
H/O jaw surgery was done secondary to cancer 3 year's ago
No TB,
Epilepsy,Asthma.
Personal history:
Appetite: lost
Diet _mixed
Bowel:regular
Bladder: decreased output
Addiction : alcohol occasionally stopped 1 year back
Family history:.
Not significant
General examination;
pallor present,
No icterus,cyanosis, clubbing,pedal edema+ no lymphadenopathy
Vitals
Temp- afebrile
PR - 85 bpm
BP- 90/50 mmHg
RR- 16CPM
Systemic examination
CVS- S1,S2 heard,no murmurs
RS - BLAE, NVBS
Per abdomen ; abdomen distended, non tender
CNS - patient is conscious coherent and cooperative.
No neck stiffness
NORMAL
MOTOR SYSTEM-
TONE UL LL
RT N N
LT N N
REFLEXES
BICEPS TRICEPS SUPINATOR
RT 2+ 2+ 1+
LT 2+ 2+ 1+
KNEE ANKLE
RT 2+ 1+
LT 2+ 1+
SENSORY SYTEM - NORMAL
GLASGOW SCALE- 15/15
Provisional diagnosis; ascites with spontaneous bacterial peritonitis
Chronic liver disease
chronic kidney disease stage 4
14/11/23
S : no fever spike
Stools passed
C/o : nausea, bloating sensation
O :
Patient is conscious, cooperative
Vitals :
Temp : 98.1F
BP : 80/50 mmHg
PR : 80bpm
RR:18cpm
Spo2: 97(RA)
A:
Ascites with spontaneous bacterial peritonitis.chronic liver disease, chronic kidney disease stage 4
K/c/o CAD s/p PTCA done on 17/8/22 , k/c/o dm 2, 1 prbsc transfused on 14 /11/23
P :
1.inj NORAD 3200 mcg /min (20ml/hr-3.2 mg/hr)
2. Inj dobutamine 1500 mcg/min ( 18ml/hr -40mg/hr)
3.INJ dopamine 534 mcg/min (8ml/hr_ 32mg/hr)
4.inj monocef 1gm iv/bd 12 th hourly
5 inj zofer 4mg iv/bd
6.inj hydrocartisone 50 mg iv/tid 8 th hourly
7.in pan 40mg iv /od bbf
8.tab udilive 400 mg po/od
9.tab orofer xt po/od
10. tab shelcal ct po/od
11.tab Atorvastatin 10mg po/hs
14. Fluid restrictions less than 1.5 lt /day
15. Inj hai subcutaneous pre meals 6 units
16 salt restriction less than 2 gm/day
17.2 egg white /day 18.grbs bp,pr monitering hourly 20. Syp lactulose 15ml in 1 glass water po/tid
SOAP Notes : icubed 2
15/11/23
S : no fever spike
Stools passed
C/o : hematuria
O :
Patient is conscious, cooperative
Vitals :
Temp : 98.1F
BP : 100/60 mmHg
PR : 80bpm
RR:20cpm
Spo2: 98(RA)
A:
Ascites with spontaneous bacterial peritonitis.chronic liver disease, chronic kidney disease stage 4
K/c/o CAD s/p PTCA done on 17/8/22 , k/c/o dm 2, 1 prbsc transfused on 14 /11/23
P :
1.inj NORAD 2amp in 46mlNs (/hr-3.2 mg/hr)
2. Inj dobutamine 1500 mcg/min
3.INJ dopamine 2.5mcg/kg/min (8ml/hr_ 32mg/hr)
4.inj monocef 1gm iv/bd 12 th hourly
5 inj zofer 4mg iv/bd
6.inj hydrocartisone 50 mg iv/tid 8 th hourly
7.inj pan 40mg iv /od bbf
8.tab udiliv 400 mg po/od
9.tab orofer xt po/od
10. tab shelcal ct po/od
11.tab Atorvastatin 10mg po/hs
14. Fluid restrictions less than 1.5 lt /day
15. Inj hai subcutaneous pre meals 6 units
16 salt restriction less than 2gm/day
17.2 egg white /day 18.grbs bp,pr monitering hourly 19. Syp lactulose 15ml in 1 glass water
1.List all the complaints of the patient with respect to the history and relevant clinical data and mention the treatment plan for each listed problem and mention treatment plan stating it's efficacy in relevance to patient relief and better outcome.
C/o abdominal distension since 20 days
abdominal bloating sensation since 20days
Bilateral Pedal edema since 6months
k/c/o diabetes 2 since 10 years
K/c/o CAD s/p PTCA done on 17/8/22
K/C/O CKD , CLD
2) What are the possible causes of pedal edema
chronic liver failure
Renal failure
Heart failure
ECG;
4) what is the cause of ascitis physiology?
Ans :Ascites occurs when there is a disruption in the pressure forcea between intravascular and extravascular fluid spaces which allows extravascular fluid to accumulate in the anterior peritoneal cavity.
6). What are the most common causes of ascitis??
Ans: portal cirrhosis of liver congestive cardiac failure, malignancy, hepatitic vein obstruction
7) What infection is caused by ascitis??
Spontaneous bacterial infection is an Infection of fluid that accumulates in the abdomen. Spontaneous bacterial peritonitis is an infection of abdominal fluid, called ascites, that does not come from an obvious place within the abdomen, such as a hole in the intestines or a collection of pus.
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