gm e-log

Hi all, this is Mounika, a 5th sem  medical student
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings investigations and come with a diagnosis and treatment plan. 
DOA: 18/07/2022
A 55 yr old female presented to the casuality with complaints of yellowish discoloration of eyes and generalised weakness. 
Chief complaints
Yellowish discoloration of eyes since 20 days. 
Generalised weakness since 20 days. 
Decreased response to commands since yesterday night

History of present  illness
Patient was apparently asymptomatic 20 days back and developed a fever associated with burning micturition and yellowish discoloration of eyes for which she came to our hospital and advised admission but attenders doesn't want to get admitted. 
Then she used some herbal medication on every monday for 2 weeks(I.e.. She used medication for 2 times) during which she skipped antihypertensives and antidiabetics. 
Then she was fine until yesterday night and slept having dinner. Then she wake up at 2:00 AM for urination but she has difficulty in passing urine and couldn't pass urine. So she slept again and woke up at 5:00 AM and started developing sweating and weakness. 
History of past illness
K/c/o hypertension and DM since 6 years and on irregular medication
no CAD, TB, asthma, epilepsy. 

Treatment history
For diabetes and hypertension she was using medications since 6 years . 
For HTN: Tab. AMLONG 5 mg PO/OD
For DM: Tab. METFORMIN 500mg.,Tab. GLIMIPIRIDE 

Personal History
Diet : mixed
Appetite: normal
Bowel movement: irregular
Micturition: Abnormal
Addictions: toddy drinker occasionally but stopped after diagnosed with HTN and DM
Family history 
No relavent family history
General Examination 
Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built

There are no signs of
Cyanosis
Lymphadenopathy
Clubbing
There is presence  of 
Icterus

VITALS
Temperature: 98 degree Fahrenheit
Pulse rate: 84 per min
Respiratory rate: 18 per min
BP: 140/90 
SpO2: 99% 
GRBS: 54mg%
Systemic Examination
CVS
S1 S2 heared
No murmurs

RESPIRATORY system 
Dyspnoea : no
Wheeze : no
Postion of trachea: central

ABDOMEN 
Shape of abdomen: obese
There is no free fluids
Liver and spleen is not palpable
Bowel sounds are normal

CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15




Investigations
On 01/07/2022
On 18/07/2022
2D Echo
ECG

Ultrasound
Diagnosis
Viral hepatitis

Treatment

On 18/07/2022
IVF-DNS 50ml
INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml PO

On 19/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm  IV/BDS
TAB. RIFAGUT 550 mg Po/BD

On 20/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm  IV/BDS
TAB. RIFAGUT 550 mg Po/BD
TAB. PCM 500 mg PO/BD
INJ. TRENEXA 500 mg IV/STAT
SYP. AROSTROZYME 25ml PO/TID



Comments

Post a Comment

Popular posts from this blog

gm E-log log

Image
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.  Date of Admission: 19/7/22 CHIEF COMPLAINTS  This is a case of 70yr old male ,who presented to the casualty with Chief Complaints of involuntary movements of upper limbs and lower limb with involuntary micturition  HOPI Patient was apparently asymptomatic 5 months back and them he developed brain stroke for which he uses medication which should be continued for lifelong and on 19 July he presented to casualty with an episode of seizure which involved involuntary movements of both upper and lower limbs and involuntary micturition. After admitting he developed another 2 episodes of seizures with in...
Read more

65 Yr old male with DKA with community acquired pneumonia and prerenal AKI

Image
Hello all this is J. Mounika, a nineth semester student.This E Log depicts the patient centered approach to learning 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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references   A 65 year old male was brought to casualty with CHIEF COMPLAINTS Fever since 4 days Breathlessness since 1 day HISTORY OF PRESENTING ILLNESS   Patient was apparently asymptoma...
Read more

Prefinal OSCE

1.RR in tachypnea?  -The normal respiratory rate (RR) for adults at rest is typically in the range of 12 to 20 breaths per minute. Tachypnea is generally defined as a respiratory rate that exceeds this normal range,  that is respiratory rate higher than 20 breaths per minute in adults considered tachypneic. 2.why there is tachypnea in community acquired pneumonia (CAP)despite a normal SpO2 reading of 99% ?  Reasons for tachypnea in CAP: Ventilation-Perfusion Mismatch: Pneumonia can lead to a mismatch between ventilation (airflow) and perfusion (blood flow) in the lungs. Even with adequate oxygen levels in the inhaled air, the exchange of gases in the affected areas of the lungs may be compromised, triggering a respiratory response. Increased Work of Breathing: The body's effort to overcome the decreased lung function and maintain sufficient oxygen supply to the bloodstream can result in tachypnea, despite the overall oxygen saturation appearing normal. 3.Respiratory findi...
Read more