Monday 20 December 2021

50 year old male with SOB since 10 days

 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.




50 years Years old male came to OPD with cheif complaints of shortness of breath since 10 days.
Complaints of decreased urine output,nausea,B/L pedal edema and  constipation since 10 days.

Patient was aparently asymptomatic 15 years back, then developed B/L pedal edema , shortness of breath and was brought to our hospital 1 session of HD done.Patient was diagnosed with CKD 15 years back and was treated conservatively(on and off).

Now again 10 days back he came to OPD.

Past History :-

K/C/O HTN since 10 months and on regular medications.
Not a known case of DM , asthama , TB , Thyroid , epilepsy.

Personal History :-

Diet : mixed
Apetite : decreased since 10 days.
Sleep : adequate.
Bowel movements : irregular
Decreased urine output.

No any addictions.


On examination, patient is C/C/C .
Pallor present.
B/L pitting edema present till knees.







No cyanosis , icterus, clubbing , lymphadenopathy.
Temperature - 98.5*F
PR - 112/ min
RR - 18cpm
BP - 110/90 mmhg
Spo2 - 99% at RA
Grbs - 115 mg%

CVS :- S1 , S2 heard
RS - BAE present
P/A - soft and non tender
CNS - No focal Neurological deficet.


RFT :-

Serum Albumin :-

USG :-


Serology:-

Serology :-

Serology:-


CBP:-

CUE:-



Provisional diagnosis :-

Chronic kidney disease with Polycystic kidney disease and K/C/O HTN since 10 months.

Updates 
(18/12/21)Day 2 :

Urea :- 219 mg/dl
Creatinine : 17.5 mg/dl
Hb : 5.2 gm%
 
1 session of HD was performed on 18th along with transfusion of 1 unit of PRBC.

S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.

O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID

(19/12/21 )day 3:

Urea : 109 mg/dl
Creatinine : 11.3 mg/dl
Hb : 7.4 gm%

S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.

O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID

(20 /12/21)Day 4:

Urea : 115 mg/dl
Creatinine : 11.2 mg/dl
Hb : 6.8 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.

S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.

O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID

Day 5 (21/12/21)

Urea : 42 mg/dl
Creatinine : 4.9 mg/dl
Hb : 8.4 gm%
1 session of HD was done.

S :-
B/L Pedal edema present.
Decreased urine output.

O :-
BP - 150/80 mmhg
PR - 83 bpm
Temp - afebrile
RR -17cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID

Day 6 (22/12/21)

Urea : 36 mg/dl
Creatinine : 2.9 mg/dl
Hb : 9.1 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.

S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.

O :-
BP - 130/80/90 mmhg
PR - 82 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID

Day 7 (23/12/21)

Hb : 9.8%




S :-
B/L Pedal edema present.
Decreased urine output.

O :-
BP - 130/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -17cpm
Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

Saturday 18 December 2021

65 year old with fever , myalgia and radiculopathy



 "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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment


65 year old male ,farmer hailing from nagarjun sagar came to casualty with chief complaints of

● fever since 5 days

● backache since 5 days 


History of present illness:

>Patient was apparently asymptomatic 5 days back , then developed high grade continous fever with chills, rigors  subsiding on medication(injections taken)

>There was 1 episode of vomiting - non projectile , food particles as contents , no blood 

>he had sharp pain in the back radiating to his legs , not relieved on medication  ,associated with myalgia

> patient initially had difficulty to pass stools , but gradually was relieved of the problem

>No complaints SOB,cough,burning micturition

Past history :

>5 years back patient had complaints of increased micturition (polyuria)
and was diagnosed as diabetic for which he was on insulin .Inj.MIXTARD 10U(morning) and 8U(night).

>4 years ago patient came to our hospital with c/o SOB and was told to have lung infection ,?mass . He was admitted for 5 days,was advised to stop smoking and drinking 

>Since 4 years patient had skin lesions with scaling over legs and hands which progressed gradually, for which he used steroids and tapered.As the lesions kept progressing patient underwent skin biopsy 1month ago at another hospital which showed munromicroabscess suggestive of psoriasis. He has been using medication for psoriasis since 1 month.

>H/O unstable angina 1 and half year back-PCA  was done.

>Not a K/C/O HTN,TB,asthma,epilepsy, thyroid disorders.

Personal history:

▪︎Diet-mixed
▪︎Appetite-normal
▪︎sleep-adequate
▪︎Bowel and bladder movements-regular
▪︎Smoker and alcoholic since 25 years but its been over 4 years he stopped both smoking and drinking 

Family history:

Not significant

General examination:

Patient is conscious, coherent, cooperative and is moderately built

No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema.

Vitals on admission: day 1
Temperature-99 F
PR-64 bpm
RR-18 cpm
BP-80/60 mmHg

Systemic examination:

CVS-S1,S2 heard,No murmurs
RS-BAE present
CNS-No FND
P/A-soft,non tender

Clinical images:

Psoriatic plaques on B/L upper and lower limbs:











Investigations:








Provisional dignosis:

Left lower lobe pneumonia ( bacterial > viral)
With H/O PCA 1 and half year back
With K/C/O DM-type 2
Psoriasis vulgaris 


Treatment:

IVF NS @150 ml/hr-bolus given
             @75 ml/hr- maintenance 
TAB.DOLO 650MG TID
INJ.NEOMOL 1G IV SOS
Temperature charting 4th hrly
INJ.AVIL 2CC SOS(IF CHILLS +)
GRBS monitoring 6th hrly
INJ.HUMAN ACTRAPID ACCORDING TO GRBS
TAB.ECOSPIRIN 75/20 MG PO OD
INJ.PIPTAZ 4G IV QID

Updates

Day 2:
S-  c/o headache and backache
No fever spikes
O-
Pt isC/C/C
Temp- 97.7 F
BP- 120/80 mmHg
PR- 100 bpm
CVS- S1S2 +
RS- BAE+, crepts + in Lt. IAA
P/A- soft, non tender
DM-II +
P- 
IVF NS,RL,DNS @75ml/hr
INJ. PIPTAZ 3.375 IV QID
TAB. DOLO 650 mg PO TID
INJ. NEOMOL 1 gm IV SOS
INJ. AVIL 2 cc IV SOS
Inj.PAN 40mg IV OD
INJ. HUMAN ACTRAPID S.C. According to GRBS
TAB. ECOSPIRIN-AV (75/20) mg PO OD
Temp charting 4th hourly
Grbs 6th hrly

Day 3:
S-  
One episode of vomiting today morning
Low backache +, Headache+
No fever spikes
O-
Pt isC/C/C
Temp- 97.7 F
BP- 120/80 mmHg
PR- 100 bpm
CVS- S1S2 +
RS- BAE+, crepts + in Lt. IAA
P/A- soft, non tender
Low back pain (2° to ? Radiculopathy)
Leg raising test + at 45° in Left Leg, 60° in Right Leg
P- 
IVF NS,RL @100ml/hr
INJ. PIPTAZ 3.375 IV QID
TAB. DOLO 650 mg PO TID
INJ. NEOMOL 1 gm IV SOS
INJ. AVIL 2 cc IV SOS
Inj.PAN 40mg IV OD
Inj.ZOFER 4mg IV BD
INJ. HUMAN ACTRAPID S.C. According to GRBS
TAB. ECOSPIRIN-AV (75/20) mg PO OD
TAB. VITRACET 1/2 PO QID
Temp charting 4th hourly
Grbs 6th hrly

Day 4 :
S-  
One episode of vomiting today morning
Low backache +, Headache+
No fever spikes
O-
Pt isC/C/C
Temp- 97.7 F
BP- 120/80 mmHg
PR- 100 bpm
CVS- S1S2 +
RS- BAE+, crepts + in Lt. IAA
P/A- soft, non tender
Low back pain (2° to ? Radiculopathy)
Leg raising test + at 45° in Left Leg, 60° in Right Leg
P- 
IVF NS,RL @100ml/hr
INJ. PIPTAZ 3.375 IV QID
TAB. DOLO 650 mg PO TID
INJ. NEOMOL 1 gm IV SOS
INJ. AVIL 2 cc IV SOS
Inj.PAN 40mg IV OD
Inj.ZOFER 4mg IV BD
INJ. HUMAN ACTRAPID S.C. According to GRBS
TAB. ECOSPIRIN-AV (75/20) mg PO OD
TAB. VITRACET 1/2 PO QID
Temp charting 4th hourly
Grbs 6th hrly

 Day 5:
S- c/o low backache +
Nausea +, pain abdomen on and off
Chills+ on and off every 4-6hrs
No fever spikes
O-
Pt isC/C/C
Temp- 97.7 F
BP- 120/80 mmHg
PR- 88 bpm
Grbs-130 mg/dl
CVS- S1S2 +
RS- BAE+
P/A- soft, non tender
P- 
IVF NS,RL,DNS @75ml/hr
INJ. PIPTAZ 3.375 IV QID
TAB. DOLO 650 mg PO TID
INJ. NEOMOL 1 gm IV SOS if temp >101°F
INJ. AVIL 2 cc IV SOS
Inj.PAN 40mg IV BD
Inj.ZOFER 4mg IV TID
Tab.METFORMIN 250mg PO OD
TAB. ECOSPIRIN-AV (75/20) mg PO OD
Inj.METACHLOPRAMIDE 1amp IV STAT
Temp charting 4th hourly
Grbs 6th hrly

Day 6:
S-  c/o low backache (reduced)
Nausea +
Chills+(reduced)
No fever spikes
O-
Pt isC/C/C
Temp- 98.7 F
BP- 150/90 mmHg
PR- 96 bpm
Grbs-115 mg/dl
CVS- S1S2 +
RS- BAE+
P/A- soft, non tender

P- 
IVF NS,RL,DNS @100ml/hr
TAB. DOLO 650 mg PO TID
INJ. NEOMOL 1 gm IV SOS if temp >101°F
INJ. AVIL 2 cc IV SOS
Inj.PAN 40mg IV BD
Inj.ZOFER 4mg IV TID
Tab.METFORMIN 250mg PO OD
TAB. ECOSPIRIN-AV (75/20) mg PO OD
Inj.METACHLOPRAMIDE 1amp IV STAT
Temp charting 4th hourly
Grbs 6th hrly

Patient discharged was discharged today(20th December )

Saturday 4 December 2021

ACUTE GASTROENTERITIS

 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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

Sasira Kasinadhuni 

ROLL NO 166

A 80 yr old Male presented with chief complaints of --

Vomitings 3 episodes 
loose stools 3 episodes
Fever since 1 day

HOPI -  
Patient was apparently asymptomatic 2 years back , then he had decreased urine output following which he was taken to near by hospital and was diagnosed with ? renal failure for which he was prescribed some medication and treated accordingly.
Patient c/o 3 episodes of vomitings which were non bilious, non projectile and had food particals as contents,
3 episodes of loose stools, watery in consistency not associated with blood.
H/o fever since yesterday morning, high grade (101 degree F) , they went to local hospital where his GRBS was 500mg/dl , then referred here to KIMS

Past history-

? K/c/o ckd with decreased urine output - has been using a tablet for urine output

N/k/c/o HTN , DM

PERSONAL HISTORY -
married,farmer by occupation with normal appetite and mixed diet , regular bowels, decreased urine output , alcoholic without other addictions

FAMILY HISTORY
Not significant

VITALS @ ADMISSION
Temperature: 100 degrees F
Pulse Rate: 94/min
RR:17cpm
BP: 80/60mmHg
SpO2: 91% at Room air
GRBS: 193 mg/dl

On examination:
NO Pallor, icterus, clubbing, cyanosis , lymphadenopathy and Edema
CVS: S1S2 +
RS : BAE + NVBS
P/A: Soft , Non tender
CNS: Intact , NAD

PROVISIONAL DIAGNOSIS:

ACUTE GASTROENTERITIS 2° to VIRAL
PRE-RENAL ARI (Resolved)

INVESTIGATIONS -

COMPLETE BLOOD PICTURE (CBP)
HAEMOGLOBIN: 13.0gm/dl
TOTAL COUNT: 11,100 cells/cumm
NEUTROPHILS: 86%
LYMPHOCYTES: 11%
EOSINOPHILS : 01%
MONOCYTES: 02%
BASOPHILS:00%
PLATELET COUNT: 1.61lakhs/cu.mm
SMEAR-
Normocytic normochromic with
neutrophilic leukocytosis

LIVER FUNCTION TEST (LFT)
Total Bilurubin : 0.81 mg/dl
Direct Bilurubin: 0.20 mg/dl
SGOT(AST): 27 IU/L
SGPT(ALT) : 25 IU/L
ALKALINE PHOSPHATE: 137 IU/L
TOTAL PROTEINS : 6.6gm/dl
ALBUMIN: 4.2gm/dl
A/G RATIO: 1.82

RFT 
UREA: 104mg/dl
CREATININE:2.9mg/dl
URIC ACID:6.4mg/dl
CALCIUM:10.1mg/dl
PHOSPHOROUS:4.0mg/dl
SODIUM:135mEq/L
POTASSIUM:3.6mEq/L
CHLORIDE:90mEq/L

USG



CUE
             
FBS- 197 mg/dl
HbsAg Rapid - NEGATIVE 
HIV RAPID- NON REACTIVE 
ANTI HCV ANTIBODIES- NON REACTIVE
TROPONIN I - NEGATIVE 

Treatment 
on 30/11/21

1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY

Update - 

●On 1/12/21
O/E pt conscious
BP - 80/60mmhg
PR - 90bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND

1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
Drink 200 ml after each loose stool

2D echo report - 


● On 2/12/21
O/E pt conscious
BP - 100/60mmhg
PR - 90bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND

1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
  ▪︎Advised high potassium diet
 ▪︎Stool sample microscopy ,fundoscopy and FLC advised

● On 3/12/21
O/E pt conscious
BP - 110/60mmhg
PR - 76bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND

1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water
 
Advised Referrals- 

Opthalmology-

Gastroenterology-


Fundoscopy- No DR 
FLC- absent/normal

●On 4/12/21
O/E pt conscious
BP - 100/70mmhg
PR - 82bpm
Cvs- S1,S2 +
RS - BAE+
P/A - Soft and non tender
CNS - No FND

1)IVF:1 NS,1DNS, 1RL @100ML/HR
2)INJ.PAN 40 IV/OD
3)INJ.ZOFER 4 MG IV/SOS
4)INJ. OPTINEURON 1 AMP 100ml NS IV/ OD
5) TAB. DOLO 650 MG TID
6)INJ.METROGYL 500 MG IV/ TID
7)BP/ PR / TEMP MONITORING 4th HOURLY
8) GRBS 8th HOURLY
9)INJ CIPROFLOXACIN 500mg/IV/BD
10)Cap AD 100/po/BD
11)ORS satchets - 1 packet in 1 liter of water

Stool sample-  






fecal leukocyte count - no pus cells seen
No ova/cyst

▪︎Patient advised to be shifted to ward

5/12/2021

O/E pt conscious
PT IS C/C/C
PR: 86bpm
BP: 110/70mmHg
RR- 18cpm
RS: BAE+
CVS: S1S2 +
P/A: soft,non tender
CNS: NO FND

1)IVF DNS&RL @100ml/hr
2)Inj. PAN 40mg /IV/OD
3)Inj. ZOFER 4mg/IV/SOS
4)Inj. METROGYL 500mg/IV/TID
5)Inj. OPTINEURON 1amp in 100ml NS/IV/OD
6)Tab. DOLO 650mg/PO/TID
7)Inj. HAI SIC acc. to sliding scale 
8)Inj. CIPROFLOXACIN 500mg BD
9)Cap. REDOTIL 100mg BD
10)ORS sachets in water 
100ml/PO/ after every episode of loose stools
11)Inj. HAI s/c
12)BP/PR/Temp charting
13)Tab. SPOROLAC-DS 1 tab po/BD

 6/12/2021

O/E 
PT IS C/C/C
PR: 84bpm
BP: 110/70mmHg
RR- 18cpm
RS: BAE+
CVS: S1S2 +
P/A: soft,non tender
CNS: NO FND

1)IVF DNS&RL @100ml/hr
2)Inj. PAN 40mg /IV/OD
3)Inj. ZOFER 4mg/IV/SOS
4)Tab. DOLO 650mg/PO/TID
5)Inj. HAI S/C acc. to sliding scale 
6)ORS sachets in water 
100ml/PO/ after every episode of loose stools
7)BP/PR/Temp charting
8)GRBS Charting 4th hrly

>Patient has been discharged on 6th december


Internship assessment

 This blog is made based on my experience that showcases my competency and pitfalls UNIT duties —-First 15 days (12/12/22-26/12/22)         ...