85 yr old male with swelling on right side of the Chin.
Name:B.Shradha.
Rollno:10.
8th semester.
Under the Guidance of Dr.Divya ma'am(Intern).
This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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:
85 yr old male From Nalgonda,presented to the OPD with the...
CHEIF COMPLAINTS:
#The patient came to the casaulity with complaints of
*Swelling of Right Lower Jaw , associated with throat pain, Since 15days.
*Difficulty in swallowing,since 15 days.
HISTORY OF PRESENT ILLNESS:
#SWELLING - Sudden in onset,Progressive.
- Extending from Right Infra maxillary to middle of Neck.
-It was macerated &Pus was drained from swelling and from mouth.
-Their was No Intra oral Extension.
#DIFFICULTY IN SWALLOWING-
* Due to pain -patient was on liquid diet,Since then .
* Patient was taken to Private Hsptl
On 20/5,then his vitals were Stable& put on IV Antibiotics & Patient came on LAMA.
*Then they visited Our dental dept
On 27/5 ,when Pus was Sent for Culture ,Came to be Sensitive only for Tigecyclin.
ACINETOBACTER Sps Isolated.
#ON DAY :-(1)
PAST HISTORY:
*Patient is a known case of Hypertension,
Since 8yrs.
* He has under gone a surgery for kidney stone removal.
*He has a history of tooth extraction 30 days back.
DRUG HISTORY:
* Antihypertensives:- On Tab.Telma 40mg.
FAMILY HISTORY:
* Not Significant .
PRESENT HISTORY:
* Diet - Mixed.
*Appetite-Nrml.
*Bowel and bladder movements- Regular.
*Sleep - Adequate.
*Addictions-None.
GENERAL EXAMINATION:
*Patient is Thin built,Conscious ,Not oriented to time place and person.
#Vitals:
*Pulse rate-118bpm.
*Bp-110/70 mmHg.
*Resp rate -14Cpm.
*Temp- 98'F.
* Pallor was present .
*No -cyanosis,Icterus,Koilonychia,General lymphadenopathy.
*Pedal edema -present upto B/L Knee&
B/L UL Swelling-Present.
SYSTEMIC EXAMINATION:
# RS - BAE (+).
# CVS- S1,S2 (+)
#PA- Soft ,Non tender.
#CNS- HMF Intact.
INVESTIGATIONS:
ON-18/05/2021.
*Hb: 10.5.gm/,dl
*TLC :28,600. Cells/cum
*Platelet count -3.5lakh/mm3
*Ser.Creatinine:2.5.mg/dl
*Urea: 56 mg/dl
ON-19/05/2021
*TC :25,200cells/cumm
*Ser.creatinine: 2.0mg/dl
*Urea : 81mg/dl
ON 28/05/2021
*Ser.creatinine: 0.84mg/dl
*Urea :22 mg/dl
ON 05/06/2021
*Ser.Creatinine: 2.8mg/dl .
ON-03/06/2021
*Anti-HCV: Non reactive.
*HBsAg: Negative.
*HIV:Non Reactive.
LFT-03/06/2021.
*Total Bilirubin : 1.77mg/dl
* Direct Bilirubin: 0.47mg/dl
*SGOT :619 IU/L
*SGPT: 233 IU/L
*Alkaline phosphate: 195 IU/L
RFT -03/06/2021.
*Total Protein: 4.2 g/dl
*A/G ratio:0.82 g/dl
*Uric acid:8.6 mg/dl
*Calcium:7.2 mg/dl
*Phosphorus:5.1mg/dl
*Sodium:135 mmol/L
*Potassium:5.6mmol/L
*Chloride:97 m mol/L
#CBP-04/06/2021.
*HB:-9.4gm/dl.
*TLC:-48,000cells/cumm.
*Neutrophils:-87%
*Lymphocytes:-02%
*Eosinophils:-01%
*Basophils:-00%
*Platelets:-3.9lakh/mm3
*SMEAR- Normocytic Normochromic Anaemia with Neutrophilic Leukocytosis.
ON-05/06/2021.
#BLOOD GAS VALUES:-
*PH - 7.16
*Pco2-42.7mmHg
*PO2- 120 mm Hg.
#OXIMETRY VALUES-
*ctHb -8.0g/dl.
*sO2-94.5%.
#ELECTROLYTE VALUES:-
*cNa+ - 123mmol/dl.
*cK+ - 4.7mmol/dl.
*cCa+2- 0.30mmol/dl.
*cCl- - 95mmol/dl.
#CALCULATED VALUES:-
*cHCO3-(pst)c - (-14.3 mmol/L).
*cHCO3-(p)c - (-14.6 mmol/L).
*cBase(B)c- (-12.8mmol/L).
*cBase(Ecf)c- (-12.4mmol/L).
*ctCO2(B)c- 33.0 Vol%.
*ctCO2(P)c- 35.8Vol%.
*Anion gapc- 13.2mmol/L
*Anion gapK+c -. 17.9mmol/L.
*c Ca+2(7.4)c mmol/L.
*ctO2e - 10.8Vol%.
# 2D ECHO.
#X RAY- CHEST-
# ECG-
On -18/05/2021.
*Sub cutaneous Fat.
*Cellulitic changes In Right parotid Region ,Right side of Neck.
TREATMENT:-
# On -02/06/2021.
(1) Head end Elevation
(2) Inj. NOR ADRENALINE 1AMP IN 50ml NS/IV INFUSION@ 2ml/hour.
(3) INJ. PANTOP 40mg IV/OD.
(4) INJ. TIGECYCLINE 50mg/IV/BD IN 100 ml NS INFUSION.
(5) RT Feeds 100ml of milk with protein powder/2nd hourly.
(6) Temperature charting 4th hourly& Tepid sponging.
(7) INJ. NEOMOL 1gm/Iv INFUSION IF Temperature >101°F.
(8) TAB. PCM 650mg/TID/RT.
(9) Moniter BP, PR, RR.
(10) I/O CHARTING.
(11) GRBS -CHARTING 8th hourly.
# ON -03/06/2021-
(1) IVF - NS 1L-Bolous given.
(2) INJ. NA 2AMP IN 48ML NS @4ML/hour.
(3) INJ. TIGECYCLIN 50mg IV /BD.
(4) INJ. PANTOP 40mg IV/OD.
(5) INJ. ZOFER 4mg IV/SOS.
(6) Moniter BP, PR, Temperature, RR.
(7) I/O -CHARTING.
(8) GRBS - 6th hourly.
(9) STOP - ANTI - HYPERTENSIVES UNTIL FURTHER INSTRUCTIONS.
#ON-04/06/2021.
(1)IVF NS ,Continous Infusion @100ml/hr.
(2).INJ . NORADRENALINE@2ml/hr.(2 amp in 50ml NS).
(3).INJ. PAN 40 mg /Iv/OD.
(4).INJ.TIGECYCLINE 50mg in 100ml NS/IV/BD.
(5).Tab.PCM 650mg /sos.
(6).Monitor BP,PR,RR,GRBS 6th hrly.
(7).Strict I/O charting.
PROVISIONAL DIAGNOSIS:
# SEPTIC SHOCK SECONDARY TO PAROTID GLAND SWELLING(PAROTID ABSCESS)
DEATH SUMMARY:-
07/06/2021:(7:30Am).
*84yr old male came to the casuality in semiconscious state with BP -80/50mmHg,SpO2 70% on RA, patient was Stabilised with IV fluids and O2 Supplementation.
*Provisional diagnosis as Shock secondary to Sepsis.
*Patient was started on IV antibiotics ,IV fluids,,RT feeds and regular dressing to Right parotid abscess.
*Though the patient was on Regular Dressing &IV Antibiotics , sepsis not resolving &Started on Inotrophs as patient is on Refractory Hypotension .
*On 05/06/2021, at 4:00PM-
Pt had sudden cardiac arrest ,BP/PR -not recordable,CPR 2 cycles done,Patient Revived and Intubated Immediately and kept on mechanical Ventilation (IPPV),
With Vt :380 , I:E -1:4 ,FiO2- 100%,
*Post intubation vitals -Central pulses(+)
Pulse -feeble,BP -not recordable,SpO2-96%
With FiO2-100%.
*Patient was on Inotrophs (NA @ 12ml/hr).&Started on vasopressin@1.2ml/hr.
Increase/decrease According to maintain MAP =65mm of Hg.
*Patient was on Mechanical Ventilation (IPPV) with serial ABG'S showing Metabolic Acidosis.
*Patient was maintaining blood pressure on Ionotrophe for 1 day .
*On 07/06/2021 at 6:30 Am
Sudden Cardiac arrest ,BP/PR not recordable ,Pupils not reactive to light ,
CPR -Intiated According to AHA guidelines.
*Despite the above treatment & resuscitation patient couldn't be revived and declared death on 07/06/2021 at 7:15AM.
"Thank you Dr.Divya ma'am for Guidance."
"Thank you Dr.Rakesh Biswas sir for the opportunity."
