Evidence based date wise workflow logs collated by the intern with clickable and verifiable links
1. Case 1:
72 year old female, C/O weakness and slurring of speech
26/08/23
Ward: ward
Unit: 3
DOA: 23/08/23
S:
Episodes of vomiting
O :
Right facial nerve palsy
CVA - ISCHEMIC STROKE SECONDARY TO ACUTE INFARCT IN LEFT MCA TERRITORY
A:
No icterus, cyanosis, clubbing, lymphadenopathy.
BP - 130/90 mmhg
PR - 78 bpm
RR - 16 cpm
GRBS - 134 mg/dl
CVS - S1 S2 Heard
RS - BAE +
P/A - Soft, non-tender
P:
1. IV fluids NS 0.9 @75 ml/hr
2. Inj. Magnex forte 1.5 gm IV/BD
3. Inj. Metrogyl 500mg IV/TID
4. Inj. HAI S/C TID
5. Tab. Amlodipine 5 mg PO/OD 8AM
6. Tab. Ecospirin AV 75 mg PO/OD
7. Tab. Paracetamol 650 mg PO/SOS
8. GRBS 7 Profile
9. Regular dressing
10. Inj. Diclofenac 20 mg IM/OD
11. Monitor vitals 4th hourly
PaJR:
https://chat.whatsapp.com/JqIk6KGDFlEH19wQlVm0Pa
BLOG:
https://mahithaakireddyfmg07.blogspot.com/2023/08/72-f-co-deviation-of-mouth-to-left-side.html
2. Case 2:
65 F with B/L pedal edema and DECREASED URINE OUTPUT
C/O B/L pedal edema, facial puffiness and decrease urine output since 4 days.
HISTORY OF PRESENTING ILLNESS:
Pt was apparently asymptomatic until 4 days back, then she developed blisters of toes of both legs, after which she developed pedal edema and facial puffiness, associated with decreased urine output.
H/o fever, burning micturition, associated with itching are present.
H/O pain in the right flank region since 5 days.
No H/O cough, orthopnea, SOB, PND.
No H/O Similar complaints in the past.
PAST HISTORY:
H/O DM since 2 years , on OHAs.
K/C/O CKD since 6 months, not on conservative management.
Not a K/C/O HTN, CVA, CAD, Thyroid disorders, epilepsy, asthma, TB.
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel- normal
Bladder- burning micturition present.
date: 4/9/2023
ward: AMC
S: C/o decreased urine output . Bilateral pedal edema subsided.
O: On examination,
pt is conscious, coherent and cooperative.
Pallor is present.
No icterus, cyanosis, clubbing, lymphadenopathy.
Edema subsided.
BP: 140/80 mmhg
PR: 104 bpm
temp: 98.4 F
SPO2: 97%
GRBS: 131 mg/dl
CVS: S1S2 Heard. No murmurs.
RS: BLAE+ , NVBS
P/A: soft, nontender. Bowel sounds heard.
CNS: NFND.
7 points GRBS:
8 am: 118 mg/dl
10 am: 90 mg/dl
2 pm: 186 mg/dl
4 pm: 121 mg/dl
8 pm: 137 mg/dl
10 pm: 131 mg/dl
2 am: 130 mg/dl
A: CHRONIC KIDNEY DISEASE (STAGE 5) with type 2 DM and OHA induced hypoglycemia (resolved)
P:
1) Fluid restriction < 1.5 L/ day
2) salt restriction <2 gm/day
3) inj. HAI S/C TID before meals 4U-----4U--------4U
4) tab Lasix 40mg PO/BD
5) tab nodosis 500 mg PO/BD
6) tab orofer - XT PO/BD
7) tab shelcal - CT PO/OD
8) GRBS 7 points monitoring
9) strict I/O monitoring
10) vitals monitoring 4th hourly
PaJR:
https://chat.whatsapp.com/Kc3VyOnyoHS1NFHEU1siIS
BLOG:
https://mahithaakireddyfmg07.blogspot.com/2023/09/65-f-with-bl-pedal-edema-and-decreased.html
3. Case 3:
60 year old female with C/o loss of near vision in both eyes
12/9/23
ward: AMC
DOA: 11/9/23
S - C/o loss of near vision in both eyes since 2-3 years and watery eye discharge with itching in both eyes since 1 year.
She also has complaints of alopecia, weight gain, loss of appetite.
No C/O constipation and cold or heat intolerance.
k/c/o hypertension since 6 months. Not on any antihypertensive medication.
K/C/O Hypothyroidism and on tab. Thyronorm 25 mcg regularly.
H/ O hemithyroidectomy done 3 years back.
O - Hypertension since 6 months.
A: On examination
Patient is conscious coherent and cooperative.
No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.
She has a horizontal scar on the anterior aspect of neck with regards to the history of hemithyroidectomy surgery done 3 years back.
Vitals:
Temp: 97.8 F
PR: 96 BPM
BP: 200/100 MM/HG
RR: 18 CPM
GRBS: 130 MG/DL
SPO2: 99%
CVS: S1 ,S2 heard
RS: B/L AE present , NVBS +. No added sounds
P/A: Soft, non tender, no organomegaly.
No rigidity,Guarding.
CNS: NFND
INVESTIGATIONS:
HEMOGRAM:
HAEMOGLOBIN 13.2
TOTAL COUNT 7,800
PCV 40.1
MCV 83.7
MCH 27.6
PLATELET COUNT 1.91 Lakhs
RBS 81
CUE :
ALBUMIN Nil
SUGAR Nil
PUS CELLS 2-3
RFT:
Blood Urea 28
Serum Creatinine 0.9
SODIUM 137
POTASSIUM 4.2
CHLORIDE 101
T3, T4, TSH
T2 1.08
T4 11.37
TSH 3.50
ECG : NORMAL SINUS RHYTHM.
P:
1. Tab. THYRONORM 25 MCG PO/OD before breakfast
2. tab amlodipine 5 mg PO/OD
3. Tab. Met-xl 50 mg PO/ BD
4. Tab atarvastatin
5. strictly Monitor BP.
PaJR:
https://chat.whatsapp.com/IGXQQoXzAKgLdWlUxeCJ9T
BLOG:
https://mahithaakireddyfmg07.blogspot.com/2023/09/60-y-f-with-complaint-of-loss-of-near.html
4. Case 4:
C/O SOB, CHEST PAIN AND GIDDINESS SINCE 2 MONTHS.
HISTORY OF PRESENT ILLNESS:
PT WAS APPARENTLY ASYMPTOMATIC UNTILL 2 MONTHS BACK THEN HE DEVELOPED CHEST PAIN WHICH WAS NON RADIATIING, LOCALIZED. HE GETS EXERTIONAL DYSPNEA WITH CHEST PAIN WHILE WALKING, WHICH RELIEVED UPON REST. HE ALSO C/O SOB AND GIDDINESS SINCE 2 MONTHS.
NO C/O ORTHOPNEA, PND AND PEDAL EDEMA.
O C/O FEVER, NAUSEA, VOMITING, HEADACHE, COIGH, COLD, LOOSE STOOLS, BURNING MICTURITION.
PAST HISTORY:
KNOWN CASE OF HTN SINCE 2 YEARS ( ON UNKNOWN MEDICATION)
KNOWN CASE OF DM 2 SINCE 2 YEARS ( ON TAB. GLIMI 1 MG PO/OD)
KNOWN CASE OF CVA 2 YEARS BACK AND WAS TOLD THAT HE HAS AN INFARCT IN THE BRAIN.
HE HAS A HISTORY OF PREVIOUS SURGERY FOR RENAL CALCULI 15 YEARS AGO.
NOT A KNOWN CASE OF TB, EPLIEPSY, ASTHMA, THYROID DISORDERS, CAD.
PERSONALHISTORY:
DIET - MIXED
APPETITE IS ADEQUATE
BOWEL AND MICTURITION ACTIVITY IS NORMAL.
ALCOHOL AND TOBACCO CONSUMPTION WAS STOPPED 15 YEARS AGO.
----------------------------------
15/9/2023
S : C/O SOB, CHEST PAIN AND GIDDINESS PRESENT.
O:
ON EXAMINATION:
PT IS C/C/C
TEMP- AFEBRILE
BP- 150/80 MM HG
PR- 76 BPM
RR- 18CPM
GRBS - 163 MG/DL
CVS - S1S2 HEARD. NO MURMURS
RS- BLAE +, NVBS
P/A- SOFT NONTENDER. NO ORGANOMEGALY. BOWEL SOUNDS HEARD.
CNS- NO FOCAL NEUROLOGICAL DEFECITS.
INVESTIGATIONS:
RBS - 121 MG/DL
HEMOGRAM:
HB- 12.7
TLC - 7400
PCV- 39.5
MCV- 80.5
MCH- 25.9
PLT- 1.81 lakhs
RFT:
B. UREA- 28
S. CREAT- 2.0
Na- 134
K - 3.8
CL- 102
LFT:
TB - 0.64
DB- 0.20
AST- 14
ALT- 10
ALP -145
TP- 6.3
ALB - 3.8
2D ECHO:
- TRIVIAL TR+. NO MR/AR
- NO RWMA. NO AS/MS. SCLEROTIC AV.
- GOOD LV SYSTOLIC FUNCTION
-DIASTOLIC DYSFUNCTION+
NO PAH/PE
A:
HEART FAILURE WITH PARTIAL EJECTION FRACTION
WITH H/O CVA 2 YEARS AGO.
K/C/O HTN AND DM SINCE 2 YEARS.
P:
1. TAB ECOSPIRIN -AV(75/10) PO/HS AT 9PM
2. TAB GLIMI 1 MG PO/OD AT 7 AM
3. TAB VERTIN 8 MG PO/SOS
4. GRBS 7 PROFILE MONITORING
5. TAB AMLODIPINE 5 MG
PaJR: https://chat.whatsapp.com/Fr5gfhMKjSK5rYdmhJXuX3
BLOG:
https://mahithaakireddyfmg07.blogspot.com/2023/09/68-ym-with-co-sob-chest-pain-and.html
5. Case 5:
32year old male with Generalized Tonic Clonic seizures and hypoglycemia
19/9/23.
S: C/O hypoglycemia, sweating
O:
On examination:
The patient was conscious, coherent, cooperative.
He is malnourished and poorly built
Pallor present
Clubbing present- stage 3
Lymphadenopathy present
No cyanosis, edema
BP = 100/70 MMHG
PR= 76 BPM
RR = 20 CPM
SPO2 = 98%
GRBS = 198 mg/dl
CVS: s1, s2 heard, no murmurs
RS: bae +, reduced breath sounds on right side
Signs of volume loss present on the right side
P/A: soft, tenderness present in epigastrium
Skin: Keloid present on the chest, post inflammatory hyper pigmented macules (Herpes infection ) 3 months ago.
INVESTIGATIONS:
18/09/2023
CUE:
ALBUMIN +
SUGAR Nil
PUS CELLS 2-4
HEMOGRAM:
HAEMOGLOBIN #10.1
TOTAL COUNT # 14,500
PCV #30.2
MC V #75.5
MCH #25.3
PLATELET COUNT 2.72
LFT:
Total Bilurubin 0.68
Direct Bilurubin 0.15
SGOT(AST) #85
SGPT(ALT) 36
ALKALINE PHOSPHATE # 447
TOTAL PROTEINS #5.7
ALBUMIN #3.31
A/G RATIO 1.38
RFT:
SERUM CREATININE: 0.9
Blood Urea 11
CALCIUM 9.1
SODIUM 134
POTASSIUM 2.2
CHLORIDE 101
RBS #78
SERUM AMYLASE 47
SERUM LIPASE 18.0
ABG:
PH 7.43
PCO2 27.7
PO2 107
HCO3 18.1
02 Sat 97.2
---------------------------------------------------
19/9/2023:
HEMOGRAM:
HAEMOGLOBIN #9.0
TOTAL COUNT # 12,000
PCV #27.1
MCV #76.3
MCH # 25.4
PLATELET COUNT 1.86
RFT:
Serum Creatinine 0.9
Blood Urea 12
SODIUM 141
POTASSIUM 3.0
CHLORIDE 102
A:
1. Adrenal insufficiency secondary to:
a) pulmonary TB
b) HSV infection (post infection)
2. Generalized tonic seizures secondary to hypokalemia
3. Hypokalemia
4. Pulmonary TB since 6 months (on HRE)
5. Chronic calcific pancreatitis
6. K/c/o DM 2 since 1 year
P:
1. IV fluids - NS, RL, DNS @ 100ml/hr
2. Iv pan 40 mg IV/OD
3. Inj KCL 2 amp(40mcg) in 500 ml NS over 5 hours
4. Inj calcium gluconate 1g in 100 ml ns IV
5. Inj. Mg 840 2g in 100ml NS slow IV
6. HAI through S/C.
7. Tab Isoniazid -225 mg
Rifampicin- 450mg
Ethambutol-825mg
8. Syp. potchlor 15 ml in one glass of water
PaJR:
https://chat.whatsapp.com/GDYeL14n8LHCVprqJseIUK
BLOG:
https://mahithaakireddyfmg07.blogspot.com/2023/09/32-ym-with-generalized-tonic-clinic.html
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