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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 PLIGHT OF STAIRS, ON LIFTING WEIGHTS, PROGRESSED TO ORTHOPNEA IN 1 WEEK
PEDAL EDEMA DECREASING WITH LIMB ELEVATION
COUGH SINCE 6 DAYS ASSOCIATED WITH SPUTUM SMALL AMOUNTS, WHITE COLOUR, NON FOUL SMELLING , NOT ASSOCIATED WITH BLOOD , NO COLD, NO FEVER ,NO WHEEZE,
NO CHEST PAIN,NO PALPITATIONS , NO SYNCOPAL ATTACKS
H/O HOSPITALIZATION FOR RIGHT HEART FAILURE- WET BERI BERI 1 YEAR BACK
8 MONTHS BACK ADMITTED IN OUR HOSPITAL WITH AIDP/?DRY BERI BERI
KNOWN ALCOHOLIC SINCE7 YEARS TAKES 360 ml/day 3-4 TIMES A WEEK
C/O CONSTIPATION SINCE 1 MONTH
HIS FATHER IS KNOWN DM+
PATIENT IS CONSCIOUS COHERENT COOPERATIVE
BP-140/90mmHg
PR-94 BPM
RR -24CPM
SPO2-98 AT RA
GRBS -90mg/dl
WEIGHT -72KG
O/E
B/L PEDAL EDEMA +
NO PALLOR, NO ICTERUS ,NO CYANOSIS, NO CLUBBING, NO LYMPHADENOPATHY
CVS-S1S2 + , LOUD S1 + IN TRICUSPID AREA, RAISED JVP +
RESP- DYSPNEA GRADE II TO IV, ORTHOPNEA +
ABDOMEN - SOFT, TENDERNESS IN RIGHT ILIAC REGION
CNS :
Tone- normal
Power :- upper limb
RT LT
5/5 5/5
Reflexes :- RT. Lt
B. + +
T. + +
S. + +
K. - -
A. - -
Plantar. F. F
INVESTIGATION :
LFT:
RFT
PROV. DIAGNOSIS
? ALCOHOL FATTY LIVER DISEASE
? RIGHT HEART FAILURE
K/C/O HYPOTHYROIDISM
TREATMENT
1. FLUID RESTRICTION <1.5Lt/DAY
2. SALT RESTRICTION <2 GRAMS/DAY
3. INJ. THIAMINE 1 AMP IN 100ml NS/IV/BD
4. TAB. LASIX 40 mg/po/BD
5. TAB. THYRONORM 25 Mg/po/OD
6. BP CHARTING 8TH HOURLY
7. TAB. ULTRACET PO/BD
