06 T Krishna Harika
06 T Krishna Harika (old batch 3rd Semester)
BIMONTHLY Assignment July
GENERAL MEDICINE E- LOG
I have been given the following assignment in an attempt to read , comprehend,analyze,reflect upon and discuss captured patient centered data.
This link of the questions asked regarding the case
Question 1
Competency tested for peer to peer review and assessment:
CASE:
CASE DETAILS :
29 year old male patient with Acute on Chronic Pancreatitis
Case History :
A 29 year old male patient presented to the casualty on 10th June with chief complaints.
Chief Complaints :
1. Pain abdomen since morning
2. Vomiting since morning.
Review about given cases:
✔ She described her e log in a very elobarate manner and made it more informative.
✔ The given identified data by her clearly Shows the appropriate diagnosis of Pancreatitis.
✔ She has appropriately provided the history, Systemic Examination, Investigation,Her Diagnosis and treatment
✔ She has also given all the information about every aspect of the case which clearly Shows the diagnosis of Acute Pancreatitis
✔ She has given the treatment in appreciable manner.
QUESTION 2
Link the e-log you made this month
This is the e-blog link which i made dis month. Below is the link👇
QUESTION 3
Again a kind of peer review but this time of the renal failure cases that have been linked in the assignment.
CASE 1:
Patients with low back ache and renal failure
AKI:
CASE DETAILS:
A 58 year old male patient came to casualty with chief complaints of:
- lower abdominal pain: 1 week
-burning micturation:1week
- low back ache after lifting weights
-dribbling / decrease of urine out put:1week
-fever :1 week
- SOB , rest :1week.
CASE REVIEW:
POSITIVES:
⭐ She has described very clearly with the reports of the patient .
⭐She has appropriately provided with History, treatment given to the patient,clinical examination are presented affectively.
⭐ She has presented the case affectively and the case is easy to understand.
NEGATIVES:
⭐ Diagnosis is not mentioned
CASE 2:
Acute On CKD
CASE DETAILS:
A 75yr old male patient ,labourer by occupation,came to casuality with chief complaints of
➡lower backache since 10 days
➡ Dribbling of urine since 10 days
➡Pedal edema since 3 days
➡SOB At rest 3 days
➡ Increased involuntary movements of both upper limbs since 10 days
⭐ This Case has been Shifted to Orthopaedic department after 22/07/2021 for further treatment.
CASE REVIEW:
POSITIVES;
⭐She has presented the case with History of Present Illness and past Illness,Genral Examination, Systemic Examination, Investigation, Diagnosis.
⭐She has described the case very clearly everything she has mentioned.
⭐ In every case Vital Examination is very important ,she has mentioned very clearly.
NEGATIVES;
No Negatives
CASE 3:
CKD
CASE DETAILS:
49 yr old female , mother of 2 children, who is a house wife, apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated.
- Since 3 yrs she has history of muscle aches, for which she is using NSAIDs.
- She has h/o fever 20 days back, got treated in the local hospital, and
- Since 20 days she has generalized weakness.
- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.
- Urine output - Normal
- No fatigability , pedal oedema ,
- No SOB , facial fluffiness , yellowish discoloration of stools
CASE REVIEW;
POSITIVES;
➡ She has provided the data very clearly history of past Illness, Treatment, Personal History, Family History,Menstrual History,Obstetric History, Physical Examination, Diagnosis.
➡ She has mentioned Vitals also
➡ She has mentioned everything and cleary understood with the patient reports
NEGATIVES;
No Negatives
CASE 4 :
Patient with Coma and Renal Failure
CASE DETAILS:
⭐A Case of a diabetic with breathlessness.
❋patient was admitted to the hospital in the afternoon on 28 June,2021.
Chief Complaints :
❋ Fever and Diarrhea since 5 days (4 to 5 times a day with blood discharge)
❋Backpain (5 days ago) with abdominal pain and chest pain
❋patient was diagnosed with Type 2 Diabetes 3years ago.
CASE REVIEW:
POSITIVES ;
➡ She has presented the case very effectively she made it easy to understand with the reports she mentioned.
➡She has mentioned About Course In Hospital with Incubation and CPR Notes.
➡She has provided with, History, General Examination,Vitals , Diagnosis, Treatment.
NEGATIVES:
No Negatives
CASE 5
Patient with Coma and Renal Failure
CASE DETAILS;
A 52 year old man presented to the OPD With Chief Complaints of:
❋ Abdominal Distension from the past 7 days.
❋ Diagnosed with :
Alcoholic liver Disease
AKI secondary to UTI on CKD
Diabetic Nephropathy
Hepatic Encephalopathy grade 2
CASE REVIEW;
POSITIVES:
☆she has explained the case with History of Present Illness,Past illness, General Examination,Vitals, Systematic Examination, Diagnosis, Treatment.
☆She has mentioned the case very effectively
NEGATIVES:
No Negatives
CASE 6
Patients with Acute On CKD
CASE DETAILS:
⭐A 52 yr old male Patient Who is A farmer by Occupation.
➡ Presented in the hospital on14th June 2021 with Chief Complaints Of
✽ Fever Since 4 days
✽ Pus in Urine.
CASE REVIEW;
POSTIVES:
⛤ She has mentioned in the case about the History of Present Illness,Past History, personal History, Family History, General Examination, Systematic Examination, Investigations, Diagnosis, Treatment.
⛤ she has diagnosed with Renal AKI secondary to urosepsis with b/L hydroureteronephrosis.
NEGATIVES:
No Negatives
CASE 7
Patients with Acute on CKD
CASE DETAILS;
➡A 48 year old male with Chief complaints of Shortness of Breath
Note : This is an Ongoing case,this elog will be updated as and when we find new Information
➡ Chief complaints of;
48 year old male presented to the OPD With Chief Complaints of Breath grade 2 from the past 1 week ,which converted into grade 3 -4 from the past 4 days.
CASE REVIEW
POSITIVES;
⛤She has mentioned History of Present Illness, History of Past Illness,Drug History, personal History, Family History, General Examination, Diagnosis, Investigations, Treatment.
⛤She has mentioned about vitals .
NEGATIVES;
No Negatives
CASE 8
Patients with Acute on CKD
CASE DETAILS
A 60yr old female patient with shortness of breath and anasarca.
Chief Complaints:
A 60 year old patient came to the OPD With Chief complaints of..
Pedal edema Since 3 days
Decreased urine output since 3 days
H/o vomitings and loose stools 5 days ago
Lasted 3 days and subsided
CASE REVIEW
POSITIVES;
•she mentioned about History of Present Illness,Vitals, personal History, Investigations, Treatment.
• HRCT chest was done showing pulmonary oedema
NEGATIVES
⭐No Negatives
CASE 9
Patients With AKI
CASE DETAILS
A 43 yr old male,resident of Nalgonda came to casuality with chief Complaints of;
⛤Loose Stools Since 20 days
⛤Pedal Edema Since 20 days
⛤Abdominal distension since 20 days
CASE REVIEW;
Positives:
➡She has provided the data about patient very clearly.
➡She has mentioned about History of Present Illness, Past History, personal History, Family History, General Examination, Diagnosis, Investigations , Treatment.
NEGATIVES
No Negatives
CASE 10
Patients With AKI
CASE DETAILS
A 60 year old female presented the OPD with cheif complaints of:
*Pedal edema since 10 days
*Fever since 10 days.
CASE REVIEW
POSITIVES;
☆She has mentioned about History of Present Illness, History of Past Illness,Personal History, Family History, General Examination, Systematic Examination, Diagnosis, Treatment.
☆She has also mentioned the date and also given in the medication of particular date (treatment).
NEGATIVES
☆ No Negatives
CASE 11
Patients with AKI
CASE DETAILS
Pancreatitis In A Chronic Alcoholic With AKI
31 yrs male farmer by occupation, resident of Miryalaguda came with cc of pain in abdomen since a week
Vomiting Since a week
SOB since 2 days
CASE REVIEW
POSITIVES;
・She has mentioned about the History of Present Illness, Personal History, Systematic Examination, Diagnosis, Treatment, Investigations
・She has explained Investigation clearly .
NEGATIVES
No Negatives
QUESTION 4
CASE 1:
Patient with low back ache and Renal Failure
AKI :
COMPLAINTS:
☆ Week back ,after weight lifting
Patient had sudden onset of pain abdomen
☆By burning micturation with high fever : grade associated with chills and rigor
☆Decrease urine output associated with SOB (grade -4)
☆With no H/O chest pain, palpitations, pedal oedema, facial puffiness.
DIAGNOSIS:
☆Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2
TREATMENT:
1)IVF : -RL @ UO+ 30ml/hr
-NS
2)SALT RESTRICTION < 2.4gm/day
3)INJ TAZAR 4.5gm IV/TID
|
2.25gm IV/ TID
4)INJ PANTOP 40mg IV/OD
5)INJ THIAMINE 1AMP IN 100ml NS IV/TID
6)INJ HAI S/C ACC TO SLIDING SCALE
8AM - 2PM - 8PM
7)SYP LACTULOSE 15ml PO/TID [ To maintain stools less than or equal to 2]
8) GRBS - 6th Hourly
9)BP/PR/TEMP - 4th hourly
10) I/O - CHARTING
CASE 2
Acute On CKD
COMPLAINTS:
• Lower backache since 10days
• dribbling of urine since 10days
• Pedal edema since 3days
• SOB at rest since 3days
• Increased involuntary movements of both upper limbs since 10days .
DIAGNOSIS:
Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis ,Multifocal infectious Spondylodiscitis
Hyperuricemia 2° to Renal failure
Uraemia induced tremors( resolved)
Delerium 2° to septic /Uremic encephalopathy (resolving)
TREATMENT:
22/7/21
• Inj. Ciprofloxacin 500mg-OD
• Tab.Febuxostat 40mg -OD
• Tab.Neurobion forte -OD
• Tab.pantop 40mg-OD
• Syp.mucaine gel 15ml -TID
• Limb elevation- Crepe bandage
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day
•Tab.Ultracet 1/2 tab.-QID
CASE 3 :
CKD
COMPLAINTS :
- Since 3 yrs she has history of muscle aches, for which she is using NSAIDs.
- She has h/o fever 20 days back, got treated in the local hospital, and
- Since 20 days she has generalized weakness.
- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.
DIAGNOSIS:
Chronic interstitial nephritis secondary to plasma cell dyscariasis, (multiple myeloma - 70% plasmacytosis).
TREATMENT:
- T. PAN 40mg /PO / OD
- oral fluids upto 1.5 - 2 lit / day
- Protein - x ( plant based ) 2 tablespoon in 1 glass of milk
CASE 4:
Patient with Coma and Renal Failure
COMPLAINTS:
➡Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).
➡Back pain( 5 days ago) with abdominal pain and chest pain.
DIAGNOSIS:
DKA with AKI
TREATMENT :
Day 12
Inj. MEROPENEM
Inj. FOSFOMYCIN
Inj. CLEXANE
CASE 5:
Patient with Coma and Renal Failure
COMPLAINTS:
➡From the past 7 Days, He Complains of Abdominal Distension.
➡From the past 5 days, he complains of Constipation and has not passed stools since 5 days.
➡He also complains of altered Sleep patterns from the past 5 Days
➡From the past 7 Days, He Complains of Abdominal Distension.
➡From the past 5 days, he complains of Constipation and has not passed stools since 5 days.
➡He also complains of altered Sleep patterns from the past 5 Days
➡He has hiccups since today morning
He also Complains of pedal edema grade 2
He has hiccups since today morning
He also Complains of pedal edema grade 2.
DIAGNOSIS:
INFECTIVE ENDOCARDITIS
TREATMENT:
Day 1:
1. Inj. Monocef 1gm IV/BD
2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
3. Procto clysis enema
4. Inj. Pan 40 mg Iv/OD
5. Inj. Thiamine 200mg in 100ml NS /BD
6. Inj. HAI 6U S/C TID
Day 2&3:
Same treatment followed
Day 4:
Same treatment followed except Inj. Monocef.
Inj. Augmentin 1.2 gm IV/TID
Tab. Ecospirn 150mg PO/HS/SOS
Tab. Clopidogrel 75mg PO/HS/SOS
Tab. Atorvas 20mg PO/HS/OD added
CASE 6 :
Patients with Acute On CKD
COMPLIAINTS :
Fever since 4 days
Pus in the Urine.
DIAGNOSIS:
➡Renal AKI secondary to urosepsis with b/L hydroureteronephrosis with K/c/of DM -2 since 5 yrs with diabetic nephropathy with Anemia secondary to CKD with grade 1 bed sore.
TREATMENT:
Injection PANTOP 40mg IV/OD
Injection PIPTAZ 4.5 stat and 2.25 gm IV/ TID
Injection LASIX 40mg IV/BD
Injection optineuron 1AMP in 100ml NS slow IV/OD
Injection NEDMOL 100ml IV/SOS
Tab PCM 650mg TID
Insulin Human actrapid - 16 IU/TID
CASE 7
Patient With Acute on CKD
COMPLAINTS:
48-Year-old male presented to the OPD with chief complaints of Shortness of Breath grade -II from the past 1 week, which converted into grade -III-IV from the past 4 days
DIAGNOSIS:
HFrEF secondary to CAD; CRF
TREATMENT:
1. TAB. BISOPROLOL 5mg OD
2.TAB. NITROHART 20/37.5mg 1/2 T/D
3.TAB NICARDIA XL 30mg OD
4.TAB. GLICIAZIDE 80mg BD
5.TAB. NODOSIS 500 mg TD
6.Cap. BIO-D3 OD
7.Cap. GEMSOLINE OD
8.TAB. ECOSPRIN-AV 150/20mg OD
9.TAB.LASIX 40mg BD
10. SYP. LACTULOSE 15ml
CASE 8
Patient with Acute on CKD:
COMPLAINTS:
➡Pedal edema since 3 days.
➡Decreased urine output since 3 days.
➡H/o vomitings and loose stools 5 days ago lasted 3 days and subsided.
DIAGNOSIS:
Acute On CKD
TREATMENT:
Treatment:-
1. IV fluids
2. Tab. Pan 40 mg po OD
3. Inj. Lasix 80 mg IV BD
4. Thiamin 200 mg in 100 ml NS IV BD
5.Tab. Levocet 5 mg Po BD
6.Liquid paraffin for LIA
7.Grbs 6 th hrly
8.I/o charting, temp. Charting
CASE 9 :
Patients with AKI
COMPLAINTS:
⛤loose stools since 20 days
⛤ Pedal edema since 20 days
⛤ Abdominal distension since 20 days.
DIAGNOSIS:
⛤ALCOHOLIC HEPATITIS ,
⛤AKI SECONDARY TO ACUTE
⛤GASTROENTERITIS
⛤HFrEF SECONDARY TO CAD
⛤ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME.
TREATMENT:
⛤INJ THIAMINE 100 mg in 100 ml NS slow IV / TID
⛤INJ OPTINEURON 1AMP in 100 ml NS slow IV / OD
⛤INJ LASIX 40 mg
⛤TAB. ALDACTONE 50 mg PO / BD
⛤INJ PANTOP 40 mg IV/ OD
⛤ABDOMINAL GIRTH MEASUREMENT DAILY
⛤BP /PR/TEMP/ RR -4 hourly
⛤I/O CHARTHING.
CASE 10 :
Patient with AKI
COMPLIANTS:
pedal edema bilateral and pitting type, with decreased urine output and burning micturition.
DIAGNOSIS:
Acute kidney injury secondary to urosepsis with hyperkalemia ( resolved)
With anenmia of chronic disease
TREATMENT:
.Inj-LASIX 40mg (8am- 2pm -8pm)
.IVF-NS @ UO + 50 ml/hr
CASE 11
Patient with AKI
COMPLAINTS:
pain in abdomen since a week
Vomiting since a week
Sob since 2 days.
DIAGNOSIS:
pancreatitis in a chronic Alcoholic.
TREATMENT:
Iv fluids : NS 40 ml /hr.
IV lasix 40 mg BD .
Tab Nodosis .
IV PIPTAZ 4.5 Gms. BD
Iv 25%Dextrose. 100 ml BD
Tab . Nicardia 10 mg TID.
QUESTION 5 :-
⭐ During the span of 2 months ,I have experienced and seen many cases.I have learned many things during the clinical postings.
⭐The General Medicine Department are making us Understand the subject by theroy classes , Postings (online) and making us to make E-logs by this we are experiencing the case it was quite helpful for me
⭐For every clinical case they have guided us how to study and analyse the case.
⭐ I have learnt how to take patients History,and investigations , diagnosis
⭐we have learnt how to respect the privacy of patient and we should never expose the patient information
⭐ Personal History and family History is important for giving the right treatment.
