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

Comments

Post a Comment

Popular posts from this blog

CERVICAL TUMORS( 04 -06 Old batch students)

Image
                          CERVICAL TUMORS.                   (Pathology Assignment)  BY- 04 KAVYA SREEE(OLD BATCH)          05 NEEHA SRUTHI(OLD BATCH)          06 T. KRISHNA HARIKA(OLD BATCH)               About the cervix Cervical cancer starts in the cervix, which is the lower, narrow part of the uterus. The uterus holds the growing fetus during pregnancy. The cervix connects the lower part of the uterus to the vagina and, with the vagina, forms the birth canal. About cervical cancer Cervical cancer can grow from the surface of the cervix seen in the vagina, called the ectocervix, or from the canal going from the vagina to the uterus, called the endocervix. There are 2 main types of cervical cancer named for the type of cell where the cancer started. Other types of cervical cancer are rare. Squamous cell carcinoma  makes up about 80% to 90% of all cervical cancers. These cancers start in the cells on the outer surface covering of the cervix. [ Adenocarcinoma  makes up 10% to 20% of
Read more

04 KAVYASREE (OLD BATCH)-BIMONTHLY ASSESSMENT AUG-2021

Image
04 KAVYASREE(OLD BATCH) 3rd SEMISTER. Hi This is K.KAVYASREE, a 3rd semester medical student ."This is 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 patients clinical problems with collective current best evidence based inputs" Medicine paper for Aug 2021 bimonthly blended assessment    https://medicinedepartment. blogspot.com/2021/08/medicine- paper-for-aug-2021-bimonthly. html?m=1 Q1 )  (Testing peer review competency in the active reader of this assignment) : Please go through the long and short cases in the first link shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared
Read more

KAVYASREE KALUVALA(04 OLD BATCH) JULY 04,2021

Image
A 40 year old male patient with complaints of seizures. JULY 04,2021. I am K.Kavya sree   and this is a case that I have come across in the discussion group, described below:- A 40 year old male patient came to casualty with chief complaints of five episodes of seizures - focal (right side) with secondary generalisation associated with loc involuntary micturition since today morning for which he was taken to a local hospital and got treated symptomatically. From there he was referred to one hospital for further treatment. Pt was brought to casuality in a state of altered sensorium . GCS : E3V4 M5. H/o generalized weakness & body pains since one day. No history of fever/vomiting/headache/weakness of of UL/LL/deviation of mouth. No other complaints. Past history: Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB Personal History :  Daily wage labourer Consumes alcohol 180 ml/ day since 20 years. Cigeratte smoking  15 / day since 20 years . General examination : No pallor /icterus /cyanosis /
Read more