Beyond the blog 5

 

E-LOGS GENERAL MEDICINE

Ch.Janani

Roll no. 29

    This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

CASE SCENARIO

•A 70 year old male patient came to the casuality with pedal edema & vomiting.

CHIEF COMPLAINTS:

*c/o pedal edema since 1month  which is progressive pitting type bilateral associated with facial puffiness and vomiting.
* Shortness of breath (-)
* Oliguria (-)
* Abdominal distension (-)  
* No other complaints.

HISTORY OF PRESENT  ILLNESS:

* History of b/l pedal edema 2 years back,used medication and pedal edema resolved.
* Hiccups since 15 days.
*Vomitings since 10 days,containing food particles.
* Urinary hesitencey(+), dribbling of urine, no increase in frequency.

HISTORY OF PAST ILLNESS:

H/o pedal edema 2 years back,used medication and resolved.
k/c/o hypertension since one and half year and on regular medication  
DM(-)

TREATMENT HISTORY :

*For hypertension

PERSONAL HISTORY:

Alcohol 90ml occasionally
1 chutta per day (stopped 3 years back)
 

FAMILY HISTORY:

Not significant

PHYSICAL EXAMINATION:

* Pallor-not seen
* Icterus-not seen
* Cyanosis-not seen
* Clubbing-not seen
* Lymphadenopathy-not seen
* Edema of feet-b/l grade 2 pitting type

VITALS:

* Pulse rate-78 bpm
* BP-200/100
* SPO2-98%














SYSTEMIC EXAMINATION:

1)CVS

* S1 S2 heard, JVP(-) 













2) RESPIRATORY SYSTEM
* BAE(+) bronchial artery embolization
*AE  ( acute exacerbations) decreased on left ISA ( Intrinsic sympathomimetic activity) , IAA( interrupted aortic arch)
 

3)ABDOMEN

*Soft, scaphoid shaped abdomen 
 

4)CNS

*NAD  ( no abnormality detected)

PROVISIONAL DIAGNOSIS:

Acute on chronic renal failure (sepsis induced)
Analgesic nephropathy
Thrombophlebitis

INVESTIGATIONS:


1/10/21 
*Serum creatinine-6.9 mg /dl
*Uric acid -7.8 mg %

CUE:

*Colour-Pale yellow
*Appearance-Clear
*Reaction-Acidic
*Specific gravity-1.010
*Albumin-+++
*Sugar,bile salts,bile pigments,crystals,casts,amorphous deposits-Absent
*Pus cells-(5-6)
*Epithelial cells-(3-4)
*Rbc-(5-6)

HEMOGRAM:

*Haemoglobin-17.8
*Total count-17000 cells/mm3
*Neutrophils-85
*Lymphocytes-5
*Eosinophils-4
*Monocytes-6
*Basophils-0
*PCV-55.4
*MCV-72.4
*MCH-23.3
*MCHC-32.1
*RBC count-7.65
*Platelet count-1.98
*SMEAR-
RBC-microcytic hypochromic
WBC-neutrophilic leucocytosis

2/10/21
 
*Serum creatinine-7.4mg/dl
SERUM ELECTROLYTES:
*Sodium-130
*potassium-3.9
*chloride-107

BLOOD UREA-123mg/dl

URINE PROTEIN/ CREATININE RATIO:
*spot urine protein-210mg/dl
*spot urine creatinine-52.5mg/dl
ratio-4

3/10/21

Urea-135
creatinine-7.4

 4/10/21











TREATMENT:

30/9/21

* SALT RESTRICTION<2gm/day
* FLUID RESTRICTION<1l/day
* IVF NS VO+ @ 30m/hr,RL
*INJ LASIX -40m IV BD
8am-4pm-V
(If SBP>= 110mm of hg)
*MONITOR VITALS-4th hourly
*I/O chatring

1/10/21

1. fluid restriction<1.1l/day
2.salt restriction<2gm/day
3.Injection LASIX-40mg
4.I/O charting
5.Injection NEOMOL-1gm
6.Tablet DCNA-650mg
7.Temperature charting-6th hourly
8.Tab amlong-5mg
9.BP charting-4th hourly
10.Tab met-xl-25mg
 
4.10.21
*fluid restriction<1.5l/day
*salt restriction<2g/day
*INJ.lasix 40mg IV BD 
*I/O CHARTING
*INJ NEOMOL IV 
*TAB PCM 650mg PO/SOS
*TAB CLIVIDIPINE 10mg PO OD
*TAB MET- XL 25mg PO OD
*BP CHARTING 4TH hourly
*TEMP CHARTING 6th hourly 
*TAB NODOSIS 500mg PO BD 
*THROMBOPHOB Oint 

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