GENERAL MEDICINE E-LOG
B.Ananya
Roll no.18
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.
A CASE OF ANAEMIA UNDER EVALUATION WITH THYRITOXICOSIS:
This E-log has been created under the guidance of
Dr sreeja.
Introduction:A 40year old female patient who is labourer came to OPD with chief complaints of
CHIEF COMPLAINTS :
1.Cough ass c̅ sputum
2.Fever (on and off)
3.SOB @REST
4.Pedal odema
Since 15 days
HOPI:
The patient was asymptomatic 8 months back She had sudden onset of Cough-productive small quantity, not ass c̅ fever, SOB .
On taking IV fluids as prescribed by RMP patient developed SOB(grade 2 and 3) c̅ pedal odema.
Patient visited NIMS [cough and odema subsided] PE/DCMP
After 10 days sudden onset of dysnea and generalised odema is seen
Kidney biopsy done on 17/12/2020shows -inconclusive
- C3 C4 -(N) 24 hours urinary protein:471(nephrotic range)
-USG-Abd Grade 2 to 3 RPD changes
2 PRBC transfusion done
Glomerulonephritis (4)
[RBC:20-30,A/b:2+,SPC :2.98] these are regular follow up till April 2021
H/o weight loss since 2 months
H/O covid -19 (+ve) sep 2020- home isolated
15 days back 5 PRBC (Alb:4)
HISTORY OF PAST ILLNESS:
15 days ago patient again developed generalised oedema;SOB and cough.
5 OPRBC was tranfused
Inj erythropoietin was given.
Hb:4g/dlp
plt:72k
Hyperthyroidism 10 days ago
Discharged on 19/4 /21
Latest CBP 23/7/21 :Hb -7. 3g/dl
TLC-9, 270cells/mm
Plt- 1.38 lakhs
PERSONAL HISTORY:
DIET : MIXED
B/B : regular
sleep: normal
TREATMENT HISTORY:-
patient was using medications for renal failure
GENERAL EXAMINATION:-
The patient is conscious coherent cooperative
Pallor is present
No cyanosis
No icterus
No clubbing
Edema is present below upto knee(pitting type)
No lymphadenopathy
No malnutrition
SYSTEMIC EXAMINATION:-
VITALS:-24/07/2021
PR: 125bpm/min
Bp Lt arm:160/100mmHg
Temp: afebrile
SPO2: 88%
CVS:-
No thrills present
Cardiac sounds: S1,S2 (+)
Cardiac murmurs absent
JVP Increased
Parasternal haeve (+)
RESPIRATORY SYSTEM:-
Dyspnoea is present
No wheeze
Position of trachea: central
Breathe sounds: vesicular
Adventitious sounds absent
CNS:-
Patient is conscious
Speech is normal
Reflexes are normal
25/07/2021
VITALS:-
PR: 91bpm/min
Bp Lt arm:120/90mmHg
Temp: afebrile
SPO2: 88%
RR: 25/MIN
CVS:-
PARASTERNAL haeve (+)
Cardiac sounds: S1,S2 (+)
APEX BEAT : 5th intercostal space
JVP Increased
Parasternal haeve (+)
RESPIRATORY SYSTEM:-
nvbs (+)
bae(+)
p\a ratoi : soft
CNS:-
NAD
PROVISIONAL DIAGNOSIS:-
Anaemia under evaluation with tyritoxicosis
INVESTIGATIONS:-
URINARY ELECTROLYTES [NA,K]
URINE PROTEIN /CREATININE RATIO
COMPLETE URINE EXAMINATION
SERUM IRON
ANTI HCV ANTIBODIES-RAPID
HEMOGRAM
HIV1/2 RAPID TEST
HBS AG - RAPID
APTT
PROTHROMBIN TIME
ECG
TREATMENT:-
24/07/2021
INJ LASIX [40mg IV/ BD /IF ]
T. TELMA [40mmhg]
T LIVOGEN [150 mg /OD]
T MET -XC [25mg /OD]
FLUID RESTRICTION [< 1 L/DAY]
SALT RESTRICTION [ < 2 mg /day]
BP/PR/TEMP/RR- 4th hourly
STRICT I/O - charting
25/07/2021
FLUID RESTRICTION[< 1 L/DAY]
SALT RESTRICTION [<2.4gm /day]
INJ LASIX[40mg IV BD]
T.MET XL [25 mg /bd]
T. LIVOGEN [150 mg/od]
BP/PR/TEMP/RR- 4th hourly
I/O-charting
T ECOSPRIRIN [BD]
T SPIRANOLACTONE [50 mg/od]
T NIKARDIA RETARD [20 mg /TID]
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