This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input
This Elog also reflects my patient centered 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
PRESENT HISTORY
An 80-year-old male resident of Kamanpet was admitted with complaints of acute urinary and fecal retention for the past 24 hours. The patient had been in a stable condition until a month ago when he began experiencing bilateral lower limb and knee pain. He sought care at a local hospital and received conservative management. During this time, he was informed about the risk of kidney injury and advised to follow a renal diet.
Yesterday, the patient experienced an inability to defecate (accompanied by the absence of flatus) and urinate, along with shortness of breath. There is no history of fever, but the patient did report constipation two days ago.
PAST HISTORY
known case of hypertension for the past 10 Years and has been diagnosed with diabetes mellitus for the past 6 years.
Interpretation: primary respiratory alkalosis acute with secondary metabolic acidosis
ECG
CHEST X-RAY
ERECT ABDOMEN X RAY
USG ABDOMEN
Right Renal calculi e/o 6mm in the mid pole of right kidney
Right Hydrouretronephrosis
Left complex Renal cortical cysts
Grade 1 RPD changes in bilateral kidneys
2D ECHO
EF 64%
IVC Size (1.09cms) collapsing
Moderate to severe MR (eccentric MR) Mild AR/TR with PAH
No RWMA
No AS/MS, sclerotic AV
Good LV systolic function
No diastolic dysfunction, No PE
REVIEW 2D ECHO ON 23-08-2023
No RWMA
IVC 1.45cms Non collapsing
RVSP= 42+10=52mmhg
PML PROLAPSE
Moderate to severe MR (eccentric MR) moderate AR mild to moderate TR with PAH
No AS/MS, sclerotic AV
Good LV systolic function
diastolic dysfunction present,No PE
UROLOGY REFERAL
Surgery Referal
[19/08/23, 11:23:45] ✍🏼: Fecal and urinary retention
1. What are the potential causes of simultaneous acute urinary and fecal retention in an elderly patient?
2. Are there any neurological, structural, or obstructive factors contributing to the retention of both urine and feces?
Shortness of Breath:
1. How does the presence of shortness of breath correlate with the patient’s inability to defecate and urinate?
2. Could there be a cardiovascular or respiratory issue causing both the shortness of breath and the urinary/fecal retention?
3. What diagnostic tests can help differentiate between cardiopulmonary and other potential causes of shortness of breath in this context?
[24/08/23, 19:00:10] Rakesh Biswas Sir HOD GEN MED: Great questions 👏
[24/08/23, 19:02:15] Rakesh Biswas Sir HOD GEN MED: What is thw connection between heart failure and intestinal dysmotility?
Review the literature and share. We have reviewed this in the past
[24/08/23, 19:16:49] ✍🏼: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5924849/
Although constipation represents the most common clinical manifestation of colon dysmotility in critically ill patients, colon dysmotility in these patients may rarely present in the form of acute pseudo-obstruction. Acute pseudo-obstruction (ACPO), also referred to as Ogilvie’s syndrome, is defined as a clinical syndrome characterized by impairment of intestinal propulsion, which may bear a resemblance to intestinal obstruction, in the absence of a mechanical cause. Acute intestinal pseudo-obstruction may also involve the small intestine and most frequently occurs in patients with stroke, myocardial infarction, peritonitis, sepsis, and postoperatively in orthopedic surgery, cesarean section, cardiovascular or lung surgery [61-63]. The pathophysiology underlying ACPO remains rather unclear, with the prevailing hypothesis being an imbalance in colonic autonomic innervation in the setting of other predisposing factors. The clinical hallmark of ACPO is the presence of dilation of the colon on a plain radiograph. The dilation favorably involves the cecum and the ascending and transverse colon, although the left colon, including the rectum, may also be affected. The prognosis of acute intestinal pseudo-obstruction varies with the underlying clinical condition.
[24/08/23, 20:17:50] ✍🏼: Is our patient having pseudobstruction as you said sir?
[24/08/23, 20:18:19] Rakesh Biswas Sir HOD GEN MED: Do they have a reference for the last three statements here or is their clinical opinion?
[24/08/23, 20:19:03] Rakesh Biswas Sir HOD GEN MED: Shows good amount of dilatation
Diagnosis
UROSEPSIS SECONDARY TO RENAL CALCULI , HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 64%) ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE WITH DIABETIC NEPHROPATHY WITH POST RENAL AKI , PARTIAL PHIMOSIS ; RIGHT HYDROURETERONEPHROSIS WITH PROSTATOMEGALY WITH TRUE HYPONATREMIA(RESOLVING) SECONDARY TO ?DEHYDRATION , OSTEOARTHRITIS OF B/L KNEE (HYPERTENSION AND TYPE2 DIABETES).
Case History and Clinical Findings
COMPLAINTS OF SOB SINCE 2DAYS AND CONSTIPATION AND UNABLE TO PASS URINE SINCE 2 DAYS
HOPI :
PATIENT IS APPARENTLY ASYMPTOMATIC 2DAYS BACK THEN HE DEVELOPED CONSTIPATION AND UNABLE TO PASS URINE WHICH WAS INSIDIOUS IN ONSETAND UNABLE TO PASS FLATUS SINCE 1DAY
NO AGGREVATING AND RELIEVING FACTORS NO H/O FEVER
NO H/O CONSTIPATION PREVIOUSLY 2DAYS BACK NO H/O BURNING MICTURATION
NO H/O SIMILAR COMPLAINTS IN THE PAST
PAST HISTORY
K/C/O TYPE 2 DM, HTN
N/K/C/O ASTHMA, CAD, CVA, THYROID NO PAST SURGICAL HISTORY
ON EXAMINATION
PATIENT IS CONSCIOUS, COHERENT, CO OPERATIVE
NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, EDEMA TEMP- 96.3 F
PR- 68BPM
BP- 110/70MMHG GRBS- 146MG/DL RR- 16CPM
CVS- S1,S2 + RS- DYSPNEA+ SOB+
P/A: SOFT, NON TENDER
P/R- NO ANAL TAGS, ANAL TISSUE NOTED IN 6 O CLOCK POSITION AND NO FISTULAS ANAL TONE DECREASED
RECTUM LARGE
GLOVE STUNTED WITH STOOL CNS: NAD
COURSE IN THE HOSPITAL :
80 YRS MALE WAS ADMITTED WITH ABOVE MENTIONED COMPLAINTS. NECESSARY EXAMINATIONS AND INVESTIGATIONS WERW DONE AND DIAGNOSED AS HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 64%) ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE WITH POST RENAL AKI WITH PARTIAL PHIMOSIS RIGHT HYDROURETERONEPHROSIS , PROSTATOMEGALY WITH TRUE HYPONATREMIA WITH HYPERTENSION AND TYPE 2 DIABETES. THE PATIENT WAS CONSERVATIVELY MANAGED.
UROLOGY REFERRAL WAS DONE ON 18/8/23 :
- TAB TAMSULOSIN-D PO/HS X3 WEEKS
- SYP ALKASTONE B6 15ML 1/2 GLASS OF WATER PO/BD
- TAB PAN 40MG PO/OD BBF
- INJ ZOFER 4MG IV/SOS
- CAP BIO D3 PO/OD
- TAB NODOSIS PO/BD
- TAB NITROFURANTOIN 100MG PO/BD SURGERY REFERAL WAS DONE ON 22/8/23 :
- CST
- REVIEW USG ABDOMEN AND PELVIS I/V/O ABDOMINAL DISTENSION
- X RAY ERECT ABDOMEN
- CHEST X RAY (ERECT)
- REPEAT CBP , RFT , LFT
- DULCOLAX SUPPOSITORY PR/STAT (2)
- ABDOMINAL GIRTH MONITORING 4TH HRLY
- REVIEW WITH REPORTS
SURGERY REFERRAL WAS DONE ON 24/8/23 :
- CONTINUE SAME TREATMENT
- RYLES TUBE 16F WITH 2ND HRLY
- SYP CREMAFFIN 30ML PO/BD
- TAB DULCOLEX PO/OD/HS
- PLAN FOR CECT
- AMBULATE THE PATIENT
- REVIEW SOS
Investigation
FBS- 107
HBA1C- 6.7
PLBS- 197 ALBUMIN + SUGARS++
BILE SALTS /PIGMENTS- NIL NA+- 108
K+ 9.73
HB- 12MG/DL
TLC- 11100 CELLS
NEUTROPHILS- 85
LEUCOCYTES- 10
RBC- 4MILLIONS/CUMM RFT
UREA- 58
CREATININE- 2.2
URIC ACID- 5.3 NA+-126 CHLORINE- 93
2D ECHO DONE ON 19/8/23 :
- MODERATE TO SEVERE MR+; MILD AR+/TR+WITH PAH(ECCENTRIC MR+)
- NO RWMA. NO ASLMS, SCLEROTI AV
- GOOD LV SYSTLIC FUNCTIONS
NO DIASTOLIC DYSFUNCTION +; NO PE USG DONE ON 18/8/23 :
- RIGHT RENAL CALCULUS
- RIGHT HYDROURETERONEPHROSIS
- LEFT COMPLEX RENAL CORTICAL CYSTS
- GRADE I RAPID CHANGES IN B/L KIDNEYS REVIEW USG DONE ON 22/8/23 :
- VISUALIZED BOWEL LOOPS APPEAR COLLAPSED AND SHOW NORMAL PERISTALSIS
- NO ASCITES 21/8/23 :
SODIUM: 130 MEQ/L
POTASSIUM: 4.6 MEQ/L
CHLORIDE: 98 MEQ/L CALCIUM : 1.21 MMOL/L HEMOGRAM: 21/8/23 HB 9.8 GM/DL
TLC: 14400 CELLS CUMM PCV: 26.7 VOL %
RBC COUNT: 3.30 CELLS PLT: 2.47 LAKHS/CUMM RFT : 22/8/23 SODIUM:#133 MEQ/L POTASSIUM:5.0 MEQ/L CHLORIDE: 91 MEQ/L. BLOOD UREA: 54 MG/DL
SERUM CREATININE: 2.7 MG/DL URIC ACID : 5.2 MG/DL
24/8/23 : LFT :
TB: 0.82 MG/DL
DB: 0.18 MG/DL
SGOT: 23 IUL
SGPT: 20 IUL
ALP: 212 IUL
TP: 5.0 GM/DL
ALBUMIN: 3.1 GM/DL
A/G RATIO: 1.70 RFT : 24/8/23
SODIUM:#134 MEQ/L POTASSIUM:4.9 MEQ/L CHLORIDE: 97 MEQ/L. BLOOD UREA: 66 MG/DL
SERUM CREATININE: 3.0 MG/DL URIC ACID : 5.4 MG/DL HEMOGRAM: 24/8/23
HB 9.2 GM/DL
TLC: 27000 CELLS CUMM PCV: 26.8 VOL %
RBC COUNT: 3.17 CELLS PLT: 2.09 LAKHS/CUMM
REVIEW USG DONE ON 24/8/23 :
- VISUALISED BOWEL LOOPS APPEAR COLLAPSED WITH NORMAL PERISTALSIS
- NO ASCITES NOTED
Treatment Given(Enter only Generic Name)
IV FLUIDS NS @75ML/HR INJ. PAN 40MG IV/OD INJ. ZOFER 4MG IV/SOS INJ. HAI S/C TID
TAB. AMLODIPINE 10MG PO/OD
TAB METPROLOL SUCCINATE XL 25MG PO/OD
TAB ECOSPRIN AV 75/10 PO/HS
TAB METCLOPERAMIDE 10MG PO/HS INJ LASIX 40MG IV/BD
INJ MONOCEF 1GM IV/OD TAB. TAMSULOSIN-D PO/HS
TAB NITROFURANTOIN 100MG PO/BD
TAB SODIUM BICARBONATE 500MG PO/BD INJ NEOMOL 1GM IV/SOS
TAB PCM 650MG PO/TID CAP BIO D3 PO/OD
SYP ALKASTONE BC 15ML IN 1 GLASS OF WATER PO/BD SYP CREMAFFIN PLUS PO/BD
SYP DISODIUM HYDROGEN CITRATE PO/BD
NEBULIZATION WITH IPRAVENT 6TH HRLY , MOCOMIST 8TH HRLY , BUDECORT 12TH HRLY INJ VIT B12 IM/OD
GRBS PROFILE STRICT I/O CHARTING
MONITOR VITALS AND INFORM SOS
Advice at Discharge
PATIENT AND PATIENT'S ATTENDER HAVE BEEN EXPLAINED ABOUT PATIENT'S CONDITION AND ITS COMPLICATIONS AND NEED FOR FURTHER STAY IN HOSPITAL FOR FURTHER EVALUATION AND MANAGEMENT BUR THEY WANT TO LEAVE AGAINST MEDICAL ADVICE DUE TO PERSONAL REASONS (TREATMENT AT OTHER HOSPITAL).
DOCTORS , HOSPITAL STAFF AND MANAGEMENT ARE NOT RESPONSIBLE FOR ANY UNTOWARD COMPLICATIONS OF PATIENTS CONDITION.
Case 2
### Thematic Analysis of the Case
#### 1. **Coding:**
- **Acute Symptoms:** Urinary and fecal retention, shortness of breath.
- **Chronic Conditions:** Hypertension, diabetes mellitus, potential diabetic nephropathy, chronic kidney disease (CKD).
- **Imaging and Test Results:** Hydronephrosis, right renal calculi, bilateral kidney changes.
- **Hospitalization Journey:** ICU admission, kidney stent placement, focus on sepsis management.
#### 2. **Categorization:**
- **Urinary/Fecal Retention:** Acute onset, obstruction.
- **Kidney Issues:** Hydronephrosis, AKI, diabetic nephropathy.
- **Cardiac Concerns:** Heart failure, moderate-severe mitral regurgitation.
- **Multisystem Involvement:** Respiratory alkalosis with metabolic acidosis, abdominal distension, cardiovascular and renal connections.
#### 3. **Theme Identification:**
- **Acute Complications in Chronic Disease:** Urinary and fecal retention likely linked to kidney and heart function, compounded by diabetes and hypertension.
- **Multidisciplinary Management Challenges:** Coordination between nephrology, cardiology, and urology amidst critical symptoms and infection.
- **Chronic Conditions Leading to Systemic Failure:** The patient’s longstanding diabetes and hypertension create the basis for multiple organ system involvement, culminating in AKI and cardiac strain.
#### 4. **Theme Representation (Learning Points):**
- **Multisystem Failure in Chronic Disease:** This case demonstrates how longstanding conditions like diabetes and hypertension can culminate in acute renal and cardiovascular complications.
- **Importance of Timely Intervention:** Early detection and treatment of urological obstruction and CKD progression are crucial for preventing sepsis and organ failure.
- **Collaborative Care in Complex Cases:** The patient’s outcome illustrates the need for cross-specialty collaboration to manage sepsis, heart failure, and kidney injury simultaneously.
Outcome- mortality
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