Gnana Prasuna Reddy.K
1701006069
This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.
This E-log also reflects my patient centered online learning portfolio.
Your valuable inputs on comment box is welcome
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
A 46 year old male came to the casualty with complaints of drowsiness
Vitals at admission:
BP: 110/80 mm of hg
HR: 98bpm
RR: 18cpm
Temperature: 101 degree farenheit
SpO2: 98% on RA
GRBS: 124 mg/dL
General Examination:
Pallor present
No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
No visible signs of dehydration
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: Bilateral air entry is present.
Normal vesicular breath sounds are heard
P/A: Soft, Non tender
CNS:
Patient is having altered sensorium
.Cranial nerves- intact
.Motor system- normal
.Sensory system- normal
Reflexes:
Biceps
Triceps
Supinator
Knee
Ankle
Plantar
All are normal
Power- 5/5 in both upper and lower limbs
Tone- nomal in both upper and lower limbs
Meningeal signs are not seen
Investigations:
On admission
19.5.22
20.05.22
LDH- 192
21.5.22
Hemoglobin- 6.8g%
TLC- 22,500cells/cumm
Platelets- 1.4lakhs/cu.mm
Urea- 155mg/dl
Creatinine- 4.7
Uric acid- 7.1
Phosphorus- 2.0
Sodium- 126
Potassium- 2.6
Chloride- 87
22.5.22
Hemoglobin- 7.2
TLC- 17,409
Platelet count- 1.5
Urea- 162
Uric acid- 5.0
Sodium- 125
Chloride- 88
23.05.22
Culture report: Klebsiella Pneumonia positive
2D Echo:
24.2.22
Patient Complained of Sudden diminision of vision in right eye
Sent for ophthalmologic examination
Diagnosed as secondary angle closure glaucoma
Treated with timolol bd for 1 week and glycerol 5times daily for 1 week
25.5.22
27.5.22
Hb- 7
TLC- 22,000
Platelet count- 26,000
Urea- 144
Creatinine - 4.8
Uric acid-9.1
Phosphorus- 4.8
Sodium- 135
Potassium- 4.3
Chloride- 98
Fasting blood sugar- 149
29.5.22
Hb- 6.4
TLC- 14,700
Platelet count- 6000
Urea - 149
Creatinine- 4.4
Uric acid- 9.2
30.05.22
Provisional Diagnosis:
Right emphysematous pyelonephiritis Left acute pyelonephiritis Encephalopathy secondary to sepsis.
Treatment:
Day 1 to Day 3:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water
Day 4
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion
IV Fluids- NS,RL @ 100 mL/hr
SYP. POTCHLOR 10 mL in 1 glass of water TID
SYP. MUCAINE GEL 10 mL PO TID
7 point profile
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water
Day 5 to Day 10:
INJ. MEROPENEM 500mg IV BD (Day 6)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
Day 11:
INJ. COLISTIN 2.25 MU IV OD(Day 4)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
Day 12:
SDP Transfusion done I/v/o low platelet count
Pre transfusion counts:
Hb:6.2 g/dL
TLC:14700
PLt:6000
Post transfusion counts:
Hb:6.4
TLC:13700
PLt:50000
INJ. COLISTIN 2.25 MU IV OD(Day 5)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
On 7.6.22
IV fluids 50ml per hr
INJ. RANTAC 50mg IV OD
INJ. ZOFER 4mg IV TID
INJ. LASIX 40 mg IV BD
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ. ERYTHROPOETIN 4000 IU once weekly
TAB. OROFER XT PO OD
Vitals monitoring
Temperature charting
Comments
Post a Comment