GENERAL MEDICINE ELOG-1 AUG-05,2021

 KAVYA SREE

ROLL NO-04(OLD BATCH)

This is an online e log pattern to discuss case scenarios of a patient with a gardians permission.

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 a diagnosis and treatment plan.

65 year old female, house wife by occupation, came to the opd with c/o burning micturition since 2weeks. 
Generalised weakness since 2 weeks
Low backache since 1 week. 
Fever since 5-6 days

History of present illness: 

Patient was apparently asymptomatic 2 weeks back. Then she developed c/o burning micturition since 2 weeks and used tab.nitrofurantoin for 4 days and UTI subsided. Followed by c/o low backache, followed by fever since 5 days. Low grade fever not associated with chills and rigor, relieved on medication, followed by generalised weakness.
H/o covid-19 3 months back
No c/o cold, cough
No c/o chest pain, palpitations, syncopal attacks
No c/o orthopnea, PND
K/c/o Dm- 2 since 25 years. 
Medication used : lispro insulin(50%) + insulin lispro protamine(50%) (25U - X - 25U) 
Hypertension since 25 years
Medication used : pro Met-xl 50 mg
She is having similar c/o UTI twice in a year. 
H/o (?) Angina 4 years back. On isosorbide dinitrate/SOS
No h/o epilepsy, tb, asthma 
No c/o pedal edema, facial puffiness, decreased urine output. 

Personal history: 
Appetite : Normal
Bowel and bladder movements : Normal
Non alcoholic
Non smoker

Family history: 
No significant family history 
 
Patient is drowsy, coherent and cooperative

General examination : 
Patient was drowsy
Pallor +
No icterus - 
No Cyanosis 
No clubbing, lymphadenopathy and oedema
Temp : afebrile
PR : 110 BPM
RR : 24 CPM
BP : 110/80 mm of Hg
Spo2 : 98% at RA. 
GRBS : 148 mg/dl

Systemic examination : 
CVS: 
S1,S2 heard
NO thrills, murmurs.

Respiratory system: 
Trachea postion : central
Inspiratory crepts noted
B/L IAA, ISA
 
Per abdomen: 
Soft, non tender
No palpable masses 

CNS: 
All superficial and deep reflexes are normal
 
Diagnosis : AKI on CKD secondary to urosepis.
K/c/o diabetes and hypertension since 25 years
K/C/O : Hypothyroidism 
With Hypoproliferative Anemia

VITALS AND TEMPERATURE MONITORING: 



INVESTIGATIONS: 

1. ECG :

2 CHEST X-RAY [ AP SUPINE] 

•2D ECHO : 
 
• URINE FOR CULTURE SENSITIVITY : 


Microscopic picture 

3. ABG : 
ON 2/8/2021: 

ON 3/8/2021: 

ON 4/08/2021: 
  
4. Hemogram: 


5. CUE: 

5. THYROID PROFILE : 
 
6. LFT : 
 
7. RFT : 

8. Serum urea, creatinine, electrolytes : 
On 2/08/2021: 

On 3/08/2021: 


On 4/08/2021: 


9. PLBS :


10. FBS :

11. RETICULOCYTE COUNT : 

12. CUE : 

13. RTPCR :

TREATMENT : 
DAY 1 : 
Inj.Meropenem 500m Iv/BD
Inj.levofloxacin500mgIv/OD
Inj.pan40mg iv/OD 
Inj.Hai sc t.i.d
Inj.lasix40mg Iv/BD  
Strict I/O charting 
GRBS Charting 6th hourly 
Bp/PR/RR/SPO2 Charting 4th hourly 
Neb.Duolin 8th hourly 
Budecort 8th hourly
Mucomist 12th hourly 
IVF 500ml NS@u.ot 40ml/hr

Day 2 : 
Inj.Meropenem 500mgIv/bd
Inj.levofloxacin500mgIv/od
Inj.pan40mg iV/od
Inj.Hai sc t.i.d
Inj.lasix40mg Iv/bd
Strict I/O charting 
Bp/PR/RR/spo2 charting 
Neb.Duolin 6th hourly 
-budecort 8th hourly 
IVF 500ml NS @u.o+40ml/hr

Syp.lactulose15ml/po/bd

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