This is an 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 patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:

A 28 year old female who is a daily wage labourer came to casuality with complaints of fever since 10days, bilateral pedal edema since 7days, burning micturition since 3days and shortness of breath since 1day

 Patient was apparently alright till 10days back, then she had fever, which was low grade, not associated with any chills and rigors, relieves on taling medication, no aggrevating or relieving factors. From 7days she was having insidious onset of pedal edema, pitting type, not associated with facial puffiness, decreased urine output, chest pain or palpitations. From 3days she was having buring micturition and shortness of breath from 1day even at rest.

No h/o vomitings, loose stools, chest pain, palpitations

She is not a known case of DM, HTN, ASTHMA, TB, Epilepsy, CAD.

PERSONAL HISTORY

 Patient takes mixed diet, appetite is normal, bowel and bladder movements were regular, and no known drug allergies

FAMILY HISTORY

not relevent

GENERAL EXAMINATION

Patient is concious, choherent

Palor is present, no icterus, clubbing, cynosis, lymphaenopathy,

Edema present over feet

VITALS:

 temperature 98.4 F

BP: 150/90 mmhg

Pulse: 103/min

RR : 35/min

Grbs :133 mg/dl

SYSTEMIC EXAMINATION

CVS : S1, S2 heard no thrills, no murmurs

RS : Trachea position central, BAE +, NVBS +, no added sounds

P/A : soft, non tender

CNS : no abnormality detected

 


 





















0n 13/11





 PROVISIONAL DIAGNOSIS:  SEPSIS INDUCED AKI, ?LEPTOSPIROSIS WITH LEFT LOWER LOBE PLEURAL EFFUSION OR CONSOLIDATION

TREATMENT GIVEN 

INJ. HAI 8 UNITS IN 25% DEXTROSE OVER 30MIN IV STAT
NEBULIZATION WITH SALBUTAMOL 4 RESPULES STAT
INJ SODIUM BICARBONATE 100ML IV OVER 1O MIN GIVEN
INJ. CALCIUM GLUCONATE 10ML IV OVER 10 MIN GIVEN
INJ TRANEXA 1GM IV STAT GIVEN
INJ LASIX 40MG IV STAT
IVF 1U NS @ 50ML PER HOUR WITH 100meq NaHco3
INJ MEROPENEM 500MG IV STAT


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