13-2-21

This is an online E log book to discuss our patients deidentified 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 problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case I have seen : 

Unit 6 admission :

Case admitted in male ward on 6/2/2021.

Interns 

B. Mani varma 

K.Divya Rachana

K. Nikhil reddy

M. Swarna

Juveria 


 Dr. Vinay(pgy1)

Dr. Rashmitha(pgy2)

Dr. A. Vaishnavi (pgy2) 

Dr.  Sai Radha(pgy3)

Dr. Hareen (SR)

Dr.Praveen Naik( asst.proff)

55 YEAR OLD MAN PRESENTED TO THE  CASUALITY WITH THE C/O 
FEVER SINCE 1 DAY ASSOCIATED WITH BODY PAINS. LOOSE STOOLS  AND VOMITINGS SINCE 1 DAY. GIDDINESS SINCE MORNING 
PATIENT WAS OPERATED 3 YRS BACK FOR ? LIPOMA ON HIS RIGHT SIDE OF CHEST. HE WAS USED TO BE  HTN  5 YEARS BACK ARE REGULAR CHECK UP AND HAS BEEN ON REGULAR MEDICATIONS EVER SINCE. 
1 MONTH BACK, HE HAD SUDDEN FALL AFTER ALCOHOL INTAKE AFTER WHICH CT BRAIN SHOWED NORMAL. HE HAS BEEN HAVING FEVER SINCE 1 DAY, HIGH GRADE WITH CHILLS,  CONTINUOUS, ALSO ASSOCIATED WITH BODY PAINS WHICH RELIEVED AFTER RECEIVING MEDICATIONS OUTSIDE
HE HAS AROUND 15 EPISODES OF LOOSE STOOLS YESTERDAY GREENISH IN COLOUR ,SMALL AMOUNTS , FREQUENT,NON BLOOD STOOLS ASSOCIATED WITH ABDOMINAL PAIN, 4-5 EPISODES OF VOMITINGS GREENISH IN COLOUR,  NON PROJECTILE,  CONTAINING  FOOD PARTICLES 
HE HAS BEEN HAVING GIDDINESS  SINCE MORNING 
K/C/O HTN SINCE 5 YEARS 
PERSONAL HISTORY :TAKES ALCOHOL DAILY  90 ML WHISKEY EVERYDAY 
LAST INTAKE 1 MONTH BACK 
NO H/O DM, CAD, TB,  ASTHMA 
O/E : 
CONSCIOUS,COHERENT,CO OPERATIVE 
NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO LYMPHADENOPATHY, NO OEDEMA 
MILD DEHYDRATION PRESENT 
TEMPERATURE - 98.6 F
PR -86 BPM
RESP. RATE - 16/MIN
BP-90/60MMHG
SPO2- 99% AT RA
GRBS - 106 mg/dl
GENERAL EXAMINATION 
SYSTEMIC EXAMINATION :
CVS- S1S2 HEARD, NO MURMURS 
RESP SYSTEM :
BAE+ NO ADDED BREATH SOUNDS 
ABDOMINAL EXAMINATION :
TENDERNESS PRESENT  IN RIGHT  HYPOCHONDRIUM
NO FREE FLUID, BRUITS, 
NO HEPATOMEGALY, NO SPLEENOMEGALY
BOWEL SOUNDS PRESENT 
PROVISIONAL DIAGNOSIS :
?ACITE GASTROENTERITIS
? CHOLELITHIASIS
INVESTIGATIONS:

TREATMENT :
1. IVF - 2 NS, 3 RL CONTINUOUS INFUSION @ 100 ML/ HOUR
2. INJ. PANTOP 40MG/IV/OD
3. INJ. ZOFER 4MG/IV/TID
4.TAB. SPOROLAC /PO/TID
5. TAB. DOLO 650 MG/PO/SOS
6. MONITORING VITALS
7. I/O CHARTING 
8. ORS 1 SACHET IN 1 LITRE OF WATER / PO/ AFTER EACH EPISODE 
9. INJ.  METROGYL 100ML IV /TID
10. INJ CIPROFLOXACIN 500 MG/IV/BD

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This is an online E log book to discuss our patients deidentified 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 problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case I have seen :  Unit 6 admission : Case admitted in male ward on 6/2/2021. Interns  B. Mani varma  K.Divya Rachana K. Nikhil reddy M. Swarna Juveria   Dr. Vinay(pgy1) Dr. Rashmitha(pgy2) Dr. A. Vaishnavi (pgy2)  Dr.  Sai Radha(pgy3) Dr. Hareen (SR) Dr.Praveen Naik( asst.proff) 40/M, LORRY DRIVER CAME WITH C/O PEDAL EDEMA SINCE 5-6DAYS ABDOMINAL DISTENTION SINCE 5-6 DAYS COUGH SINCE 5-6 DAYS SHORTNESS  OF BREATH ON WALKING FOR LONG DISTANCES NYHA GRADE 2 TO GRADE 4ABLE TO CLIMB 2
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This is an online E log book to discuss our patients deidentified 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 problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case I have seen :  Unit 6 admission : Case admitted in male ward on 6/2/2021. Interns  B. Mani varma  K.Divya Rachana K. Nikhil reddy M. Swarna Juveria   Dr. Vinay(pgy1) Dr. Rashmitha(pgy2) Dr. A. Vaishnavi (pgy2)  Dr.  Sai Radha(pgy3) Dr. Hareen (SR) Dr.Praveen Naik( asst.proff) A 50 year old male patient resident of Nalgonda, daily wage worker by occupation came with complaints of Fever since 30 days,low grade, intermittent. Increased frequency of stools 3 times per day,non mucoi
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