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 

Comments

Post a Comment

Popular posts from this blog

general medicine practicals

Image
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.     This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan Chief complaints : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right sid
Read more

General medicine

Image
Ch Janani Roll no. 29 A female patient aged 74 yrs  came to the OPD with chief complaints of fever  ,shortness of breath ,and she had altered sensorium. Chief complaints Fever ( 7 days) Shortness of breath(4 days ) Altered sensorium ( 2-3 days) History of present illness Patient was apparently asymptomatic 10 days back and She was admitted to hospital by her family due to loss of consciousness,fever,loss of speech and altered sensorium. History of past illness N/k/c/o diabetes mellitus,CAD and CVA hypertension,TB, epilepsy,no previous surgeries. She is a known case of asthma using inhalers ( duration not known) Personal history She is married Diet : mixed Bowel and bladder movements: normal  Appetite: normal No allergies No addictions Drug history: used pain killers for pain and swelling of lower limbs General examination  Palor No cyanosis No icterus No clubbing of fingers Pedal edema present ( pitting type )  Moderately built No Lymphadenopathy Vitals   Temperature: afebrile Pulse ra
Read more

Beyond the blog

  Janani Roll no.29 Question 1 Case 1 pulmonology In the above case a 55yr old female diagnosed as problem at bronchioles. Due to exposure to dust or allergens. Some drugs have been used Bipap reduces transmural pressure,reduces venous return etc Agumentin inhibits bacterial cell wall synthesis Hydrocortisone inhibits phospholipids A2 and other inflammatory factors. Symptom generalized weakness Comment:the above case had been presented with all necessities and investigations ,and xrays. Review   https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Case 2 Neurology In this case the patient had diagnosed as wernicks encephalopathy Causes brain damage in lower parts of  thalamus and hypothalamus. This is due to chronic alcohol consumption causes impaired absorption of thiamine from intestine. Comment:the above case had been presented  with all investigations Review https://143vibhahegde.blogspot.com/2021/05/wernickes-encephalopathy.html Case 3 C
Read more