General 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.

𝑪𝒂𝒔𝒆 𝒊𝒏 𝒃𝒓𝒊𝒆𝒇-

A 49yr old female who is a municipality worker  by occupation , was brought to casuality with complaints breathlessness and fever.

#𝑻𝒉𝒊𝒔 𝒊𝒔 𝒂𝒏 𝒐𝒏𝒈𝒐𝒊𝒏𝒈 𝒄𝒂𝒔𝒆 𝒂𝒏𝒅 𝒘𝒊𝒍𝒍 𝒃𝒆 𝒖𝒑𝒅𝒂𝒕𝒆𝒅 .
𝑫𝒂𝒕𝒆 𝒐𝒇 𝒂𝒅𝒎𝒊𝒔𝒔𝒊𝒐𝒏-30/09/21
𝐂𝐡𝐢𝐞𝐟 𝐂𝐨𝐦𝐩𝐥𝐚𝐢𝐧𝐭𝐬
• SOB since 2-3days, Grade 4,Worsening
• Fever since 10days ,intermittent type ,low grade and subsides with medication.
• Pedal oedema since 6months
• Facial puffiness since 5-6months
• Reduced urine output

𝐇𝐢𝐬𝐭𝐨𝐫𝐲 𝐨𝐟 𝐩𝐫𝐞𝐬𝐞𝐧𝐭 𝐢𝐥𝐥𝐧𝐞𝐬𝐬
• C/O of cough associated with sputum,scanty since 10days
• H/o Covid vaccination 8days ago

𝐇𝐢𝐬𝐭𝐨𝐫𝐲 𝐨𝐟 𝐩𝐚𝐬𝐭 𝐢𝐥𝐥𝐧𝐞𝐬𝐬
• K/c/o  Hypertension since 1yr
• Not a k/c/o of diabetes mellitus

𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
She has been treated for hypertension :-
Tab.TELMA 40mg- irregular medication

𝐏𝐞𝐫𝐬𝐨𝐧𝐚𝐥 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
• Married
• Appetite is reduced
• Non vegetarian
• Urine outpit decreased

𝐅𝐚𝐦𝐢𝐥𝐲 𝐡𝐢𝐬𝐭𝐨𝐫𝐲
• 𝑵𝒐 𝒇𝒂𝒎𝒊𝒍𝒚 𝒉𝒊𝒔𝒕𝒐𝒓𝒚 𝒐𝒇 𝒅𝒊𝒂𝒃𝒆𝒕𝒆𝒔,𝒉𝒚𝒑𝒆𝒓𝒕𝒆𝒏𝒔𝒊𝒐𝒏 ,𝒔𝒕𝒓𝒐𝒌𝒆,𝒉𝒆𝒂𝒓𝒕 𝒅𝒊𝒔𝒆𝒂𝒔𝒆 ,𝒂𝒔𝒕𝒉𝒎𝒂 ,𝒕𝒖𝒃𝒆𝒓𝒄𝒖𝒍𝒐𝒔𝒊𝒔 ,𝒉𝒆𝒂𝒓𝒕 𝒅𝒊𝒔𝒆𝒂𝒔𝒆𝒔, 𝒐𝒓 𝒄𝒂𝒏𝒄𝒆𝒓𝒔.

𝐆𝐞𝐧𝐞𝐫𝐚𝐥 𝐞𝐱𝐚𝐦𝐢𝐧𝐚𝐭𝐢𝐨𝐧

• Well nourished and moderately built
• No pallor
• No cyanosis
• No icterus
• No lymphadenopathy
• Pedal edema
• Mild dehydration

𝑺𝒚𝒕𝒆𝒎𝒊𝒄 𝒆𝒙𝒂𝒎𝒊𝒏𝒂𝒕𝒊𝒐𝒏

𝑪𝑽𝑺
• No murmurs
• No thrills
• S1,S2 heard

𝑹𝒆𝒔𝒑𝒊𝒓𝒂𝒕𝒐𝒓𝒚 𝒔𝒚𝒔𝒕𝒆𝒎
• No dyspnoea
• Wheezing present
• Trachea is centrally placed
• Vesicular breath sounds
• Adventitous sounds -rales 1  rub

𝑨𝒃𝒅𝒐𝒎𝒆𝒏 𝒔𝒚𝒔𝒕𝒆𝒎
• No tenderness
• No palpable mass
• Scaphoid shaped abdomen
• No free fluid
• Liver and spleen are not palpable

𝑪𝑵𝑺
• Concious
• Normal speech
• No signs of meningeal irritation
• Normal sensory and motor system
𝐕𝐢𝐭𝐚𝐥𝐬
30/09/21
• 𝐓𝐞𝐦𝐩𝐞𝐫𝐚𝐭𝐮𝐫𝐞-99°𝐅
• 𝐏𝐮𝐥𝐬𝐞 𝐫𝐚𝐭𝐞- 112/𝐦𝐢𝐧
• 𝐑𝐞𝐬𝐩𝐢𝐫𝐚𝐭𝐢𝐨𝐧 𝐫𝐚𝐭𝐞 -28/𝐦𝐢𝐧
• 𝐁𝐥𝐨𝐨𝐝 𝐩𝐫𝐞𝐬𝐬𝐮𝐫𝐞-170/110𝐦𝐦𝐇𝐠
• 𝐒𝐏 𝐎2%-  82%
• 𝐆𝐑𝐁𝐒-187𝐦𝐠

1/10/21
• BP-140/90mmHg
• PR-78/min
• SP O2%-94-96% on BiPAP
• GRBS-132mg/dl

2/10/21

• BP- 130/90mmHg
• Temperature -98.6°F -Afebrile
• PR-100/min
• GRBS-187mg/dl

3/10/21
• BP -200/100mmhg
• PR-140bpm
• SP O2%-82%
• Temperature-101°F
• Respiratory rate-40/min



04/10/21
• Temprature-afebrile
• BP-130/80mmHg
• PR-102bpm
•

𝐈𝐧𝐯𝐞𝐬𝐭𝐢𝐠𝐚𝐭𝐢𝐨𝐧𝐬
2𝑫 𝑬𝒄𝒉𝒐 𝒓𝒆𝒑𝒐𝒓𝒕
• LAD territory akinetic with RCA hypokinesia
• Moderate to severe LV Dysfunction
• Mild tricuspid regurgitation with mild pulmonary artery hypertension
• Sclerotic AV
• Transient LV dilated size-5.3cm
• Diastolic dysfunction
• No Pulmonary embolism /LV clot

30/9/21

Hemogram
ABG

3/10/21

𝑻𝒆𝒎𝒑𝒆𝒓𝒂𝒕𝒖𝒓𝒆 𝒄𝒉𝒂𝒓𝒕𝒊𝒏𝒈











𝐏𝐫𝐨𝐛𝐚𝐛𝐥𝐞 𝐝𝐢𝐚𝐠𝐧𝐨𝐬𝐢𝐬
𝐇𝐅𝐫𝐄𝐅 2° 𝐭𝐨   𝐂𝐀𝐃 (𝐄𝐅-35%)
  CKD ( 4th stage)
With ? Cardiogenic pulmonary edema (resolved)

𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭

30/09/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin  and budecort  -8th hourl
• Inj.lasix 80mg i.v stat
• Inj.Nitroglycerin 1mg in 1ml i.v stat
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• Foleys catheterization

01/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin  and budecort  -8th hourly
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO, SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
•  Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm

02/10/21
• O2 inhalation (to maintain >92%)
• Nebulization with duolin 
•               budecort  -8th hourly
• Inj.lasix 40mg i.v BD
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Tab.Met-XL 50mg PO OD
• Tab.Ecosprin (75/20mg) PO
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Amlong 10mg PO OD-8pm
• Salt restriction <2.4g/day
• Water restriction 2.1L /day

03/10/21

• Dialysis
• O2 inhalation  @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Inj.Ceftriaxone 1g i.v BD
• Tab.Met-XL 50mg PO OD
•  Tab.Ecosprin (75/20mg) PO
• Tab.Amlong 10mg PO OD-8pm
• GRBS 8th hourly

04/10/21
• O2 inhalation  @6.8L(to maintain >92%)
• Inj.lasix 40mg i.v BD
• Tab.Paracetamol 650mg PO/SOS
• Inj.Pantop 40mg  i.v OD
• Inj.Zofer 4mg i.v SOS
• Tab.Paracetamol 650mg PO/SOS
• Nebulization with duolin 
•               budecort  -8th hourly
• Monitor vitals hourly
• Strict I/O charting
• GRBS 8th hourly
• Tab.Ecosprin AV (75 /25mg) PO
• Tab.Nicardia PO BD
• Tab.Arkamin 0.1mg PO /TID
• Salt restriction <2.4g/day
• Water restriction 2.1L /day



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