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 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 :
USG
LFT:
RFT
CUE
CXR
2D echo 
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

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