45 year male with Parotid swelling.

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A 45-y male patient, a farmer by occupation came with c/o  painless swelling on the right side of his face since 5 months.

The patient was apparently alright 18 months back, then he noticed a Swelling on the right side of his face, initially small in size later increased in size for which the patient had sought consultation and underwent superficial parotidectomy on 13/11/2022 and was diagnosed to be having Right Pleomorphic Adenoma, then pt c/o gradual increase in the size of the right parotid gland 

And c/o painful oral ulcer at right retromolar trigone area since 4 months.

Not a known case of  DM, HTN, BA, EPILEPSY, TB, CAD or CVA.

Personal history-

Appetite -normal

Diet-mixed

B&B -regular

Addictions- pan daily twice, since 7 years.

Image showing Right Parotid Swelling, at the time of presentation to our OP.

Oral hygiene and Ulcer at Right RMT.

ECG at the time of presentation:

Chest X-ray PA view:

Outside Investigations-

Plain + CE MRI OF NECK:

TRU-CUT Biopsy from Right Parotid Region

Incisional Biopsy from Right Parotid Gland

General examination -

Pt is conscious, coherent and cooperative 

Bp-120/80mmhg

PR-78 bpm

RR-18 cpm

Grbs-148 mg/dl

No pallor, icterus, cyanosis, clubbing, lymphadenopathy 

Systemic Examination-

CVS-S1, S2+, No murmurs 

RS-BAE+, NVBS, No added sounds

P/A-soft, non-tender

CNS-

HMF+

GCS-15/15

POWER

        RT        LT

UL- 5/5       5/5

LL- 5/5        5/5

Reflexes-

        Rt               Lt

B       ++               ++

T       ++                ++

S        ++               ++

K         ++                ++

A         ++                 ++

P    dorsiflexion

Diagnosis-RIGHT PLEOMORPHIC ADENOMA WITH RIGHT RMT ULCER

75yr male Type-2Respiratory failure with respiratory acidosis with acute CVA Lf hemiparesis(3days),Intubated I/v/o poor GCS(E1V1M4) & Hypercapnia connected to ventilator in ACMV-Vc mode

​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' problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

I've 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:A 70 year old male construction labourer by occupation was bought to casualty in unconscious state.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 20days back and later developed sob and cough not associated with sputum for which patient got treated in local hospital and the symptoms subsided on medication. Patient complained of  inability to move left arm and left leg 4days back and had fever 6hours back for which he was given p650. Patient became unconscious at 4pm and was brought here for further management and treatment.

patient is a known case of Asthma since 4 years and diagnosed denovo hypertension and is on telmisartan 40mg.

not a known case of diabetes epilepsy.

HISTORY OF PAST ILLNESS:

                       There is no history of EPILEPSY.

Treatment history:

patient is a known case of Asthma since 4 years and is on medication

K/c/o  denovo hypertension and is on telmisartan 40mg.

 ON EXAMINATION

VITALS  on admission

TEMPERATURE - Afebrile

PULSE RATE - 92 bpm

BLOOD PRESSURE - 

70/50 mmHg

RESPIRATORY RATE - 20 cpm

SPO2 - 66% @ RA

GRBS 238MG/DL

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BAE +

CENTRAL NERVOUS SYSTEM :

 GCS-E0V1M0

INTUBATION DONE on 23/5/2022

As the patient is found unconscious and vitals were unstable

Pre intubation vitals

TEMPERATURE - Afebrile

PULSE RATE - 42 bpm

BLOOD PRESSURE - 

70/50 mmHg

RESPIRATORY RATE - 20 cpm

P/a distended

SPO2 - 66% @ RA

GRBS 238MG/DL

Abg was sent and shown 

pH 7.137

Pco2 68.2

Po2 111

Hco3 17.6

S02 95

As it is showing severe respiratory failure type2 with severe respiratory acidosis and hypercapnea patient was immediately intubated with 8.5mm ET TUBE And connected to ventilator with ACMV -VC mode

PEEP-5CM H2O

VT-450

RR-18

FIO2 100%

POST INTUBATION VITALS

PULSE RATE - 84bpm

BLOOD PRESSURE - 

130/90 mmHg

RESPIRATORY RATE - 20 cpm

P/a distended

SPO2 - 96% @ RA

Post intubation Abg

pH 7.177

Pco2 55.7

Po2 176

Hco3 17

S02 99%with100fio2

 

INVESTIGATIONS

ECG 9:45pm

ECG12:10am

Abg pre intubation

Abg post intubation

2d echo report

Abg on 25/5/22

Provisional diagnosis:

 Type-2Respiratory failure with respiratory acidosis with acute CVA Lf hemiparesis(3days),AKI?,Intubated I/v/o poor GCS(E1V1M4) & Hypercapnia connected to ventilator in ACMV-Vc mode

Treatment

1.RT FEEDS 100ML MILK+100ML WATER 2ND HOURLY

2.IVF NS @50ML/HR

3.INJ CEFTRIAXONE 1GM IV BD

4.INJ NORAD( 2AMP+46ML NS)@14ML/HR

5.INJ DOBUTAMINE (1AMP+45ML NS)@2ML /HR

6.STRICT I/0CHARTING

23 year old male with left single kidney with generalised weakness

​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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

A 23year old male patient farmer by occupation came to casualty with c/o : generalised weakness since 1week.

HOPI : Patient was apparently asymptomatic 1week back, then he gradually developed generalised weakness.

PAST HISTORY : Patient is not a  k/c/o HTN,

 h/o DM, tb, epilepsy, cad, asthma.

-H/O Solitary left kidney only since birth.

Patient underwent 3 dialysis in the past.

PERSONAL HISTORY : Diet - mixed, Sleep - adequate, Appetite - normal, Bowel and bladder movements - normal.

GENERAL EXAMINATION : 

Patient is conscious, coherent, cooperative

well oriented to time and place.

No pallor, icterus, cyanosis, lymphadenopathy.

VITALS:

Temp- 98.6F

PR - 92bpm

Spo2 - 99%

RR - 16cpm

GRBS - 110mg/dl

Blood Pressure - 110/80mmhg

CVS - S1,S2+ no murmurs

RS - BAE+, nvbs heard

         no wheeze, no crepts

P/A - Soft, non tender, organomegaly

Bowel sounds +

CNS - NFND

INVESTIGATIONS

PROVISIONAL DIAGNOSIS :

Chronic renal failure with left single kidney.

TREATMENT :

1) FLUID AND SALT RESTRICTIOB

2)TAB NICARDIA 20MG PO/BD

3)TAB NODOSIS 500 PO/BD

4)TAB OROFER- XT PO/BD

5)CAP BIO- D3 PO/BD

6)INJ ERYTHROPOIETIN 5000 IU/SC/WEEKLY ONCE

7)TAB SHELCAL 500MG PO/BD.