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.

𝐂𝐚𝐬𝐞 𝐢𝐧 𝐛𝐫𝐢𝐞𝐟-
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.

𝑯𝒊𝒔𝒕𝒐𝒓𝒚 𝒐𝒇 𝒑𝒓𝒆𝒔𝒆𝒏𝒕 𝒊𝒍𝒍𝒏𝒆𝒔𝒔
• 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 .

𝑯𝒊𝒔𝒕𝒐𝒓𝒚 𝒐𝒇 𝒑𝒂𝒔𝒕 𝒊𝒍𝒍𝒏𝒆𝒔𝒔

• 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.

𝑻𝒓𝒆𝒂𝒕𝒎𝒆𝒏𝒕 𝒉𝒊𝒔𝒕𝒐𝒓𝒚
• Exacerbation when exposed to cold weather and treated with Asthalin,in childhood.

𝑷𝒆𝒓𝒔𝒐𝒏𝒂𝒍 𝒉𝒊𝒔𝒕𝒐𝒓𝒚
• 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.

𝑭𝒂𝒎𝒊𝒍𝒚 𝒉𝒊𝒔𝒕𝒐𝒓𝒚
Not significant
𝑽𝒊𝒕𝒂𝒍𝒔-
𝑻𝒆𝒎𝒑𝒆𝒓𝒂𝒕𝒖𝒓𝒆-99.4°𝑭
𝑷𝒖𝒍𝒔𝒆 𝒓𝒂𝒕𝒆-60𝒃𝒑𝒎
𝑩𝒑-70/40
𝑺𝒑𝑶2-97%
𝑮𝑹𝑩𝑺-96𝒎𝒈%

𝑮𝒆𝒏𝒆𝒓𝒂𝒍 𝒆𝒙𝒂𝒎𝒊𝒏𝒂𝒕𝒊𝒐𝒏
• No pallor
• No cyanosis
• No lymphadenopathy
• Mild dehydration
• No icterus
• No clubbing of fingers
• Pedal edema -pitting type

𝑺𝒚𝒔𝒕𝒆𝒎𝒊𝒄 𝒆𝒙𝒂𝒎𝒊𝒏𝒂𝒕𝒊𝒐𝒏
𝐂𝐕𝐒
• No thrills
• S1 ,S2 heard
• No cardiac murmurs
𝐑𝐞𝐬𝐩𝐢𝐫𝐚𝐭𝐨𝐫𝐲 𝐬𝐲𝐬𝐭𝐞𝐦
• No dyspnoea
• No wheeze
• Trachea centrally positioned
• Vesicular breath sounds
• No adventitious sounds

𝐀𝐛𝐝𝐨𝐦𝐞𝐧
• Obese
• Tenderness in epigastric and hypochodrial region.
• No palpable mass
• No bruits
• No free fluids
• Liver and spleen not palpable
• Bowel sounds are present

𝐂𝐞𝐧𝐭𝐫𝐚𝐥 𝐞𝐱𝐚𝐦𝐢𝐧𝐚𝐭𝐢𝐨𝐧

• Conscious
• Normal speech

𝐈𝐧𝐯𝐞𝐬𝐭𝐢𝐠𝐚𝐭𝐢𝐨𝐧𝐬
20/8/21

𝐄𝐂𝐆

21/8/21

𝐄𝐂𝐆

24/8/21

𝐇𝐞𝐦𝐨𝐠𝐫𝐚𝐦

𝐏𝐫𝐨𝐯𝐢𝐬𝐢𝐨𝐧𝐚𝐥 𝐝𝐢𝐚𝐠𝐧𝐨𝐬𝐢𝐬
𝐒𝐞𝐩𝐭𝐢𝐜 𝐬𝐡𝐨𝐜𝐤(resolving) 𝐰𝐢𝐭𝐡 𝐫𝐢𝐠𝐡𝐭 𝐥𝐨𝐰𝐞𝐫 𝐥𝐢𝐦𝐛 𝐜𝐞𝐥𝐥𝐮𝐥𝐢𝐭𝐢𝐬
With AKI(resolved)

𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭

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 

𝐓𝐞𝐦𝐩𝐞𝐫𝐚𝐭𝐮𝐫𝐞 𝐜𝐡𝐚𝐫𝐭𝐢𝐧𝐠