THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
A 69 year old male, daily wage labourer came to the hospital with
c/o dysphagia since 5 days
uncontrolled hiccups since 3 days
loose stools since 3 days.
HOPI:-
Patient was apparently asymptomatic 12 years back when he had a episode of fever , went to a local hospital and got his BP checked and diagnosed with hypertension. He was put on Telma-H since then but patient was not compliant and used to take the medication very irregularly.
2 years back , patient was feeling uneasy and went to a hospital and got diagnosed with Diabetes mellitus when he was put on Metformin but again patient was not compliant.
Patient c/o Diminision of vision in right eye associated with eye pain , headache radiating to neck since one month for which they went to a local hospital and patient was asked to get a CT thorax, CT abdomen and pelvis, and MRI brain
CT THORAX IMPRESSION:-
Focal Peribronchial cuffing noted in left upper lobe?infective etiology , pulmonary blebs, ? pancreatic SOL.
CT abdomen and pelvis impression:- exophytic pancreatic SOL
MRI BRAIN IMPRESSION:- ?infective etiology likely NCC/Tuberculoma.
Patient was put on Prednisolone and albendazole and was given Prednisolone acetate ophthalmic suspension, cyclopentolate 1% eye drops, Timolol maleate 0.5% eye drops.
Since one week, patient complaints of mild eye pain and headache and severe dysphagia, both to solid and liquid foods associated with loss of appetite and nausea and patient's attender observed weight loss in the patient over 5 days span.
Uncontrolled hiccups since 3 days, continuous, stopping for very short intervals.
Loose stools since 2 days, watery in consistency, associated with mucus and blood.
Past history:-
Patient is a k/c/o Hypertension since 15 years and is on Telma-H , taking irregularly.
Patient is a k/c/o Diabetes mellitus since 2 years and is on GLIMI M1, taking irregularly.
Addictions:- patient is a chronic alcoholic , since 20 years, takes 180 ml/day.
Investigations:-
Abg on admission:-
Ph- 7.34, PCO2- 15, PO2 - 93.7, HCO3- 7.9
BGT- A NEGATIVE
Hb- 12.5 g/dl ; TLC - 10,400
CUE- Sugars ++++, pus cells 3-6, RBC'S nil
UKB - Positive
Prothrombin time- 20 secs, INR - 1.4
Serology negative
CRP- Positive
RBS - 679 mg/dl
Blood urea- 114 mg/dl
LFT- TB - 3.94 mg/dl;
DB- 0.46 ; ALP 135, TP 5.3, ALBUMIN- 2.45
Serum creatinine -1.9
Serum electrolytes:- Na 134 K- 4.2 Cl 99
Urinary electrolytes Na 220 K 15 Cl 180
UPCR- 0.29
Serum amylase- 50.3, Serum lipase - 18.1
Chest X ray
Treatment:-
1) NBM till further orders
2) IVF NS @150ml/hr
3)INJ HAI 6U IV STAT f/b INJ. HAI 40 U in 49 ml NS @6ml/hr >/< to maintain GRBS 150-200 mg/dl
4) INJ.THIAMINE 2 amp in 100 ml NS IV OD
5)INJ.PAN 40 mg IV OD
6)INJ. ZOFER 4mg IV TID
7)INJ.NEOMOL 1gm/IV/SOS if temp>_102F
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