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.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
Unit 1 admission
Amc
A 74 year old female came with complaints of fever since 4 days,generalised weakness since 4days
SOB on exertion since 3 days,which progressed to SOB on rest today morning
H/o two episodes of vomiting 1 day ago
Hopi:
Pt was apparently asymptomatic 4 days ago,c/o fever,highgrade,intermittent,not associated with chills and rigors
Associated with generalized weakness, two episodes vomitings,subsided on its own
SOB on exertion then progressed to SOB on rest since today morning
H/0 ?pericardial effusion 1year ago,diagnosed,on medication for 6 months later subsided
No h/o orthopnea,pnd
No pain abdomen,loose stools
Past history:
K/c/o Dm since 3 years
K/c/o hypothyroidism since 10 years on regular medication
Personal history:
Diet:mixed
Appetite:normal
Bowel,Bladder:regular
No addictions
General examination
Pt is c/c/c
Pallor+,no icterus,cyanosis, clubbing, lymphadenopathy,edema
Vitals
Pr-86bpm
Bp-100/70mmhg
Rr-24cpm
Spo2-95%@RA
Grbs-146mg/dl
Systemic examination
Cvs-s1,s2+
Rs-crepts+
Nvbs
P/a:
Soft,nontender
No palpable mass
Cns-intact
Provisional diagnosis:
LEPTOSPIRA WITH RENAL AKI WITH UREMIC ENCPHALOPATHY WITH HEPATIC ENCEPHALOPATHY GRADE 1 ( RESOLVED)
WITH DM -2 , HTN , HYPOTHYROIDISM
Investigations:
Plt at time of admission- 20,000/ cu.mm
Aptt-41.0
Inr-1.21
Dengue Ns1-negative
DengueIgG-negative
Dengue IgM-negative
Serology- negative
On 14/9/21 (morning sample)
Hb-7.9gm
Tlc-26,500 cells/ cu.mm
Rbc- 2.89 millions/ cu.mm
Plt-32000/cu.mm
Lft
Tb-8.49
Db- 6.06
Ast-87
Alt-41
Alp-314
Alb-2.36
Tp-5.9
Rft
Urea-187
Creatinine-4
Na+ 120
K+ 5.3
Cl- 96
On 14/9/21
Hb- 7.9 gm
Tlc-32,500 cells/ cu.mm
Rbc-2.89 millions/ cu.mm
Plt- 35,000 lakhs/cu.mm
Crusting of lips
Chest x ray
Repeat X ray on 17/09/21
Ecg
2D echo
ON 15 /9/21
Hb-7.4
Tlc- 30,200
Plt- 20,000
Pcv- 20.7
Urea- 237
Creatinine- 4.8
Serum electrolytes
Na+ 128
K+ 5.1
Cl- 94
Urinary electrolytes
Na+ 167
K+ 32
Cl- 196
APTT- 29 sec
PT- 14 sec
INR- 1
On 17/09/21
HEMOGRAM
Hb- 6.1
Tlc- 23,600
Plt- 30,000
Pcv-16.5
Rbc- 2.20
Thyroid profile
T3 - 0.60
T4- 4.64
TSH- 3.08
Peripheral smear
On 18/09/21
Hemogram
Hb- 6.1
Tlc-18,300
Pcv- 16.7
Rbc-2.25
Plt- 40,000
Rft:
Serum creatinine- 2.5
Blood urea- 167
Serum electrolytes
Na+ 131
K+4.1
Cl- 96
Lft:
Tb- 2.71
Db- 0.60
Ast- 50
Alt - 46
Alp- 262
Tp- 4.9.
Alb- 2.3
A/G- 0.89
On 21/9/21
Hb- 5.5
Tlc- 11,800
Rbc- 2.04
Plt- 1.1
TREATMENT GIVEN:
day 2
1)IVF (RL, NS)
2) INJ PAN 40 mg IV/OD
3) INJ ZOFER 4mgIV/ BD
4)INJ HAI S/C ACC TO GRBS( 8 am-- 1pm---8pm)
5) TAB PCM 650 mg PO/TID
6) O2 inhalatiin @ 4 lit/min
7) NEB BUDICORT( 12 th hrly)
DUBOLIN( 8th hrly)
8) INJ DOXY 100 mg PO/BD
9) INJ CEFTRIAXONE 1gm /IV/ BD
10) INJ FALCIGO 120mg IV/ STAT
11) monitor vitals
Day 3
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
4.INJ.FLACIGO 120mg IV/24hrs
5.INJ.HAI s/c TID before meals.
6.SYP.LACTULOSE 30ml PO/BD.
Day 4
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
4.INJ.FLACIGO 120mg IV/48hrs
5.INJ.HAI s/c TID before meals.
6.SYP.LACTULOSE 30ml PO/BD.
7. PROTEIN POWDER
Day 5
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
4.INJ.FLACIGO 120mg IV/48hrs
5.INJ.HAI s/c TID before meals.
6.SYP.LACTULOSE 30ml PO/BD.
7. PROTEIN POWDER
8. T.THYRONORM 100 micrograms PO/ OD
9.NEB WITH BUDICIRT, DUBOLIN
10. SYP GRILLINTUS 10 ml PO/ BD
Day 6
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
5.INJ.HAI s/c TID before meals.
6.SYP.LACTULOSE 30ml PO/BD.
7. PROTEIN POWDER
8. T.THYRONORM 100 micrograms PO/ OD
9.NEB WITH BUDICIRT, DUBOLIN
10. SYP GRILLINTUS 10 ml PO/ BD
Day 7
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
5.INJ.HAI s/c TID before meals.
6.SYP.LACTULOSE 30ml PO/BD.
7. PROTEIN POWDER
8. T.THYRONORM 100 micrograms PO/ OD
9.NEB WITH BUDICIRT, DUBOLIN
10. SYP GRILLINTUS 10 ml PO/ BD
Day 8
1.IVF NS and RL @100ml/hr
2.INJ.PANTOP 40mg/IV/OD
3.INJ.MONOCEF 1g /IV/BD
4.INJ.DOXYCYCLINE 100mg/PO/BD
4.INJ.HAI s/c TID before meals.
5.SYP.LACTULOSE 30ml PO/BD.
6.PROTEIN POWDER
7.T.THYRONORM 100 micrograms PO/ OD
10.NEB WITH BUDICIRT, DUBOLIN
11. SYP GRILLINTUS 10 ml PO/ BD
12. Inj.OPTINEURON 1 AMP IN 100 ML NS IV/OD
13.TAB.ULTRACET 1/2 TAB PO/ QID
Day 9
1.INJ.HAI s/c TID before meals.
2.SYP.LACTULOSE 30ml PO/BD.
3.PROTEIN POWDER
4.T.THYRONORM 100 micrograms PO/ OD
5.NEB WITH BUDICORT, DUBOLIN
6. SYP GRILLINTUS 10 ml PO/ BD
7.TAB.ULTRACET 1/2 TAB PO/ QID
8. CHEST PHYSIOTHERAPY
Comments
Post a Comment