Sunday, February 27, 2022

General Medicine E-Log



This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CASE:-

A 45yr old female presented with chief complaints of,
      •shortness of breath grade 3 and not                  associated with orthopnea
       •Vomiting 5-6 episodes,non projectile
       •Fever with chills(low grade)

HISTORY OF PRESENT ILLNESS:

Decrease in appetite since 3 days
Liver disease 3 months back
Vomiting with food particles as content
Abdominal pain

HISTORY OF PAST ILLNESS:-
Known case of 
Diabetes mellitus since 6years
Asthma since 4 years
Pulmonary Koch's 3 years back

TREATMENT HISTORY:

K/c/o Diabetes since 6 years and he took  medicne.
Used ATT drugs for pulmonary Koch's for 6 months.       
Not k/c/o hypertension,CAD.

PERSONAL HISTORY:

Married
Appetite-lost
Diet-nonveg
Bowel-irregular
Micturition-normal
Allergies-no
No relavent history for habits or addiction

#NORMAL ROUTINE of 45 yr old lady was waking up at 4:00a.m do all houseold work then cook and eat break fast(rice and curry).
Then goes out if needed for vegetables or stays in home and eat lunch(rice and curry) at 1-2p.m.Then eats dinner(rice and curry) after her husband comes home by 7-8p.m.

FAMILY HISTORY:

No family history of diabetes,Hypertension, heart disease,stroke,cancer, tuberculosis, asthma.

GENERAL EXAMINATION:-

Vitals:-
Temperature-98.4F
Pulse rate-121/min
Respiration rate-22/min
Bp-not recorded
Spo2 at room air-98%

Pallor-absent
Icterus-absent
Clubbing-absent
Cyanosis-absent
Oedema-absent
Lymphenopathy-absent

SYSTEMIC EXAMINATION:-

CVS:-

  • S1 and S2 heard
  • No thrills
  • No murmurs

  • Respiratory system:-

    • Vesicular breath sounds heard
    • Trachea is in central position
    • No wheezing 
    • Dyspnoea is present

    Abdomen:-
    • Scaphoid shaped abdomen
    • No tenderness
    • No palpable mass, no organomegaly
    • Bowel sounds are heard-sluggish
    • Liver and spleen not palpable 
     CNS:-
    • Drowsy and normal speech
    • No neck stiffness 
    INVESTIGATIONS:-

    ECG:-

    2D-ECHO REPORT:-

    HEMOGRAM:-
    URINE ANALYSIS:-


    PROVISIONAL DIAGNOSIS:-

    Severe Metabolic acidosis with hypovolemic shock ? Secondary to dehydration.

    TREATMENT:-

    21/10/2021

    Rx
    IVF-4 ONS- BOLUS
    Inj-NOR-ADR 8ml/hr (2 Ampin 47ml NS)
    Inj- sodium bicarbonate 100 mEQ/IV STAT
    IVF-NS,RL at 100ml/he continuous
    Inj-pantop 40mg/IV/OD
    Inj- Neomol 100ml if temp more than 101.1F
    N/H DHA's
    Inj- zofer 4 mg/IV/OD
    Inj-Ceftriaxone 1gm/IV/BD
    Inj-HAI (30ml NS)
    Inj-Sodium bicarbonate one ampuole 100ml NS
    Inj-Piptaz 4.5 gm/IV/STAT

    22/10/2021

    Patient is concious,drowsy and arousable
    Vitals:
    Bp-120/80mmHg
    Temperature-97.8F
    Pulse rate-118bpm,regular with normal vol
    Respiratory rate-20/min
    GRBS-208mg/dl
    Spo2-99% at 4lit of oxygen

    Rx
    Inj-Piptaz 2.25gm/IV/BID
    Inj-pantop 40mg/IV
    Inj-zofer 40mg/IV/SOS
    Inj-Neomol 100gm/ml
    Inj-HAI 40 units in 49ml of NS at 6ml/hr
    Tab-Dolo 650mg/PO/SOS
    Inj-Dinametazone 8mg/IV/BD
    Inj-thiamine 200mg/IV/TID