Gen.Medicine

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.

*This case is done under the guidance of dr. Bhavya

Date of admission-20/8/21

*This is an ongoing case and will be updated as and  when new information is provided.

๐‚๐š๐ฌ๐ž ๐ข๐ง ๐›๐ซ๐ข๐ž๐Ÿ-
A 32yr male patient ,who is barber by occupation,came to casuality with cheif complaints of pain in epigastric region,vomiting and fever ,injury(trauma caused due to metal belt over right leg.

๐‘ฏ๐’Š๐’”๐’•๐’๐’“๐’š ๐’๐’‡ ๐’‘๐’“๐’†๐’”๐’†๐’๐’• ๐’Š๐’๐’๐’๐’†๐’”๐’”
• Abdominal discomfort -pain in the epigastric region thrombing type and not radiating.
• Vomiting 1 episode,non-bilious,non-projectile as content.
• Right lower limb cellulitis .



๐‘ฏ๐’Š๐’”๐’•๐’๐’“๐’š ๐’๐’‡ ๐’‘๐’‚๐’”๐’• ๐’Š๐’๐’๐’๐’†๐’”๐’”
• Patient went to RMP doctor with chief complaints of epigastric pain and vomitings and was given iv fluids
• Patient had giddiness ,rotational not associated with headache,palpitations or blackouts .
• N/k/c/o Hypertension ,diabetes mellitus ,tuberculosis,epilepsy andCAD.

๐‘ป๐’“๐’†๐’‚๐’•๐’Ž๐’†๐’๐’• ๐’‰๐’Š๐’”๐’•๐’๐’“๐’š
• Exacerbation when exposed to cold weather and treated with Asthalin,in childhood.

๐‘ท๐’†๐’“๐’”๐’๐’๐’‚๐’ ๐’‰๐’Š๐’”๐’•๐’๐’“๐’š
• Married
• Barber-occupation
• Lost appetite since 1day
• Non-vegetarian
• Regular bowels
• Normal micturition
• No h/o allergies
• Regular alcoholic- 4times/day -1/2 quater -1bottle since 20yrs.

๐‘ญ๐’‚๐’Ž๐’Š๐’๐’š ๐’‰๐’Š๐’”๐’•๐’๐’“๐’š
Not significant
๐‘ฝ๐’Š๐’•๐’‚๐’๐’”-
๐‘ป๐’†๐’Ž๐’‘๐’†๐’“๐’‚๐’•๐’–๐’“๐’†-99.4°๐‘ญ
๐‘ท๐’–๐’๐’”๐’† ๐’“๐’‚๐’•๐’†-60๐’ƒ๐’‘๐’Ž
๐‘ฉ๐’‘-70/40
๐‘บ๐’‘๐‘ถ2-97%
๐‘ฎ๐‘น๐‘ฉ๐‘บ-96๐’Ž๐’ˆ%

๐‘ฎ๐’†๐’๐’†๐’“๐’‚๐’ ๐’†๐’™๐’‚๐’Ž๐’Š๐’๐’‚๐’•๐’Š๐’๐’
• No pallor
• No cyanosis
• No lymphadenopathy
• Mild dehydration
• No icterus
• No clubbing of fingers
• Pedal edema -pitting type

๐‘บ๐’š๐’”๐’•๐’†๐’Ž๐’Š๐’„ ๐’†๐’™๐’‚๐’Ž๐’Š๐’๐’‚๐’•๐’Š๐’๐’
๐‚๐•๐’
• No thrills
• S1 ,S2 heard
• No cardiac murmurs
๐‘๐ž๐ฌ๐ฉ๐ข๐ซ๐š๐ญ๐จ๐ซ๐ฒ ๐ฌ๐ฒ๐ฌ๐ญ๐ž๐ฆ
• No dyspnoea
• No wheeze
• Trachea centrally positioned
• Vesicular breath sounds
• No adventitious sounds

๐€๐›๐๐จ๐ฆ๐ž๐ง
• Obese
• Tenderness in epigastric and hypochodrial region.
• No palpable mass
• No bruits
• No free fluids
• Liver and spleen not palpable
• Bowel sounds are present

๐‚๐ž๐ง๐ญ๐ซ๐š๐ฅ ๐ž๐ฑ๐š๐ฆ๐ข๐ง๐š๐ญ๐ข๐จ๐ง

• Conscious
• Normal speech

๐ˆ๐ง๐ฏ๐ž๐ฌ๐ญ๐ข๐ ๐š๐ญ๐ข๐จ๐ง๐ฌ
20/8/21
๐„๐‚๐†
21/8/21
๐„๐‚๐†
24/8/21
๐‡๐ž๐ฆ๐จ๐ ๐ซ๐š๐ฆ






๐๐ซ๐จ๐ฏ๐ข๐ฌ๐ข๐จ๐ง๐š๐ฅ ๐๐ข๐š๐ ๐ง๐จ๐ฌ๐ข๐ฌ
๐’๐ž๐ฉ๐ญ๐ข๐œ ๐ฌ๐ก๐จ๐œ๐ค(resolving) ๐ฐ๐ข๐ญ๐ก ๐ซ๐ข๐ ๐ก๐ญ ๐ฅ๐จ๐ฐ๐ž๐ซ ๐ฅ๐ข๐ฆ๐› ๐œ๐ž๐ฅ๐ฅ๐ฎ๐ฅ๐ข๐ญ๐ข๐ฌ
With AKI(resolved)

๐“๐ซ๐ž๐š๐ญ๐ฆ๐ž๐ง๐ญ

20/8/21
• IVF -NS-20ml /kg/hr
• Inj. Ceftriaxone 1mg IV BD
• Inj.Thiamine 300mg in 100ml NS/Stat
• Inj.Pantop 80mg IV in 100ml NS
• Inj.Odansetron 4mg IV
• Inj.Tramadol 1amp in 100ml NS IV TID
• Bp,pr, 2nd hourly monitoring
• Temperature charting 4th hourly
• I/O charting

21/8/21

• IVF -NS-20ml /kg/hr
• Inj. Ceftriaxone 1mg IV BD
• Inj.Thiamine 300mg in 100ml NS/Stat
• Inj.Pantop 40mg IV in 100ml NS
• Inj.zofer 4mg IV/SOS
• Inj.Tramadol 1amp in 100ml NS IV TID
• Inj.optineuron 1amp in 100ml NS IV
• Inj. noradrenaline 2amp in 46ml NS /IV@6ml/hr.
• Inj.Metrogyl 100ml IV TID
• Bp,pr, 2nd hourly monitoring
• Temperature charting 4th hourly
• I/O charting

22/8/21
• Inj.Pantop 40mg IV in 100ml NS
• Inj.zofer 4mg IV/SOS
• Inj.Tramadol 1amp in 100ml NS IV TID
• Inj.Thiamine 300mg in 100ml NS/Stat
• Inj. Ceftriaxone 1mg IV BD
• Bp,pr, 2nd hourly monitoring
• Temperature charting 4th hourly
• I/O charting


23/8/21
• IVF -NS-20ml /kg/hr
• Inj. Ceftriaxone 1mg IV BD
• Inj.Pantop 40mg IV in 100ml NS
• Inj.zofer 4mg IV/SOS
• Inj.Tramadol 1amp in 100ml NS IV TID
• Inj.optineuron 1amp in 100ml NS IV
• Inj. noradrenaline 2amp in 50ml NS /IV@6ml/hr.
• Inj.Metrogyl 100ml IV TID
• Tab.PCM 650mg TID
• Tab.Chymoral forte TID
• Bp,pr, 2nd hourly monitoring
• Temperature charting 6th hourly and tepid sponging
• I/O charting

24/8/21
• IV fluids-NS
                                - 75ml/hr
                        RL

• Inj. Ceftriaxone 1mg IV BD
• Inj.Pantop 40mg IV in 100ml NS
• Inj.zofer 4mg IV/SOS
• Inj.optineuron 1amp in 100ml  NS - IV OD
• Inj.Metrogyl 100ml IV TID
• Bp,pr, monitoring
• Temperature charting 6th hourly
• I/O charting 
๐“๐ž๐ฆ๐ฉ๐ž๐ซ๐š๐ญ๐ฎ๐ซ๐ž ๐œ๐ก๐š๐ซ๐ญ๐ข๐ง๐ 

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