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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