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