SRINAINI
Roll no:- 33
3rd semester
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.This e-log also reflects patients centered learning portfolio.
I have done this e-log under the guidance of Dr.Rishik.
*This case has been shifted to Orthopaedic department after 22/7/21 for further treatment.
CASE IN BRIEF
A 75yr old male patient ,labourer by occupation ,came to casuality with Cheif complaints of
• Lower backache since 10days
• dribbling of urine since 10days
• Pedal edema since 3days
• SOB at rest since 3days
• Increased involuntary movements of both upper limbs since 10days .
History of Present illness
*Patient was apparently asymptomatic 10days back .
*Later developed lower backache after lifting of heavy weights 10days ago ,which is insidious in onset & gradually progressive with dull aching type of pain radiating to right lower limb,which is slightly relieved on rest and there is no diurnal variation.
*Dribbling of urine from 10days with no history of constipation ,pain abdomen . *Weakness, tingling sensation and numbness of both upper and lower limbs since 3days .There is dragging type of pain ,severe and radiating to right lower limb.
* Pedal edema which is insidious in onset & gradually progressive ,pitting type extending upto the knee .
*Involuntary movements of both upper limbs since 3days .
*No H/o of fever ,cold,cough ,chest pain ,palpitations ,and sweating .
History of Past illness
* H/o Jaundice 3yrs back which is relieved on plant based treatment.
*Not a known case of HTN ,Diabetes ,TB,Epilepsy ,CVA.
GENERAL EXAMINATION
• Consious,Coherent and Co-operative ,well oriented to time ,place and person
• Moderately built and nourished
• No pallor
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• Bilateral pedal edema ( R >L)
• Left upper limb edema
VITALS
• TEMPERATURE- Afebrile
• PR- 120bpm
• BP-120/80mmhg
• RESPIRATORY RATE -18 cpm
• SP O2 - 99% at RA
SYSTEMIC EXAMINATION
CVS Examination
• S1,S2 heard
• No cardiac murmurs
• No Thrills
Respiratory Examination
• Dyspnoea Grade 4
• No wheeze ,trachea is centrally positioned
• B/L NVBS
• No Crepts
Abdominal Examination
• Obese
• Non tender
• No palpable masses
• No free fluid
• Liver and spleen not palpable
CNS Examination
• Consious and alert
• slurred speech
• No signs of meningeal irritation
Motor system - R L
1. Power U/L - 5/5 4/5
L/L- 5/5 4/5
2.Tone U/L- N N
L/L - N Increased
3.Reflexes
Biceps - 2+ 2+
Triceps- + +
Supinator- + +
Knee- + +
Ankle- - -
• No focal and neurological deficit .
INVESTIGATIONS-
ECG, RFT, CUE, Hemogram, ABG , Serum electrolytes, Blood urea ,USG Abdomen ,LFT
13/7/21 USGABDOMEN AND PELVIS
CUE,ABG,S/E
ECG
BLOOD UREA
SERUM CREATININE
COMPLETE BLOOD PICTURE
SERUM URIC ACID
URINE CULTURE
BLOOD CULTURE
SERUM ELECTROLYTES
PHOSPHORUS
SERUM CALCIUM
Colour dopler -2D Echo
Tests done on 17/7/2021
CBP
MRI-SPINE
Investigations done on 19/7/21CBP
INVESTIGATIONS DONE ON 21/7/21Pelvis-AP view
Bacterial culture report
CBP
INVESTIGATIONS DONE ON 22/7/21Hemogram
Probable Diagnosis
• Inj.Piptaz 2.25gm I.V -TID
• Inj.Lasix 40mg I.V -BD
• Inj.Pantop 40mg I.V -OD
• Nebulization budecort -8th hourly
• T.PCM 650mg -TID
• INJ. Neomol 1mg -I.V -SOS
• Temperature charting 4th hourly
• Monitor Bp,PR
• Left U/l elevation
• strict I/O charting
• Nebulization Salbutamol 2 repluses -6th hourly
• INJ. MAI 10u in 25% D over 45min I.V
15/7/21
• IVF -NS 0.9% &DNS U.O + 30ml/hr
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Lasix 40mg I.V -BD
• Inj.Pantop 40mg I.V -OD
• Nebulization Salbutamol 2 repluses -6th hourly
• T.PCM 650mg TID-after checking Temp.
• Temperature charting 4th hourly
• Monitor Bp,PR
• strict I/O charting
• Syp. Mucaine gel 10ml -BD
16/7/21
• IVF -NS 0.9% &DNS U.O + 30ml/hr
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Lasix 40mg I.V -BD
• Oral fluids upto 2-3liters/day𝐤
• Monitor Bp,PR ,Temperature
• strict I/O charting
• Limb elevation- Crepe bandage
• Syp.mucaine gel 15ml -TID
17/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD
18/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Oral fluids upto 2-3L/day
19/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Oral fluids upto 2-3L/day
• Tab.Febuxostat 80mg -OD
• Tab.Neurobion forte -OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day
21/7/21
• Tab.Pantop 40mg -OD
• Tab.Febuxostat 80mg -OD
• Tab.Neurobion forte -OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day
• Inj.Ciprofloxacin 500mg-OD
22/7/21
• Inj. Ciprofloxacin 500mg-OD
• Tab.Febuxostat 40mg -OD
• Tab.Neurobion forte -OD
• Tab.pantop 40mg-OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day
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