General medical e log

 

This is an online E - log book to discuss our patients 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 portfolio and your valuable inputs on the comment box.

A 42 year old male farmer who is a resident of chennaram admitted in the hospital with chief complains of fever since 3days and vomiting since 3 days

Burning micturation since 3days.

History of present illness

Patient was apparently asymptomatic 3days back then developed fever insidious gradually progressive associated with chills and rigors relieved with medication .

1 episode of vomiting non bilious,non projectile ,non blood stained .

He also complained about burning micturition with increased frequency and decreased urine output since 4 days 

No history of urgency , hesitancy.

History of past illness

History of similar complaints also pedal odema , abdominal distention ,lower back pain 1 month back and was hospitalized .

MRI of lumbosacral spine shows 

Mild canal stenosis at L 4-L5

Mild canal stenosis at L3 -L4

And diagnosed to have diabetes mellitus type 2 ,CKD .

History of hospital admission in February due to abdominal discomfort  endoscopy was done and diagnosed with antral grastritis 

Know case of hypertension since 4 years 

DM since 1 month .

Treatment history 

T.S AMLO BETA 0.5 Mg 

Inj .HAI subcutaneous

Personal history 

Marital status -married

Appetite -decresed

Died -mixed

Bowel -regular

Sleep -inadequet

No allergies 

Addictions

Alcohol -weekly once 

Tobacco -snuff

Daily routine:

Patient gets up daily in between 7 to 8 am

he eats jawa for breakfast

Goes to work by 10am

He usually have his lunch by 1 pm which is mostly rice with dal

He returns home by 6 pm

His dinner is chapathi and curry most of the time

He goes to sleep by 9 pm

Family history:

None of the family members have similar complaints

General examination:

Patient was conscious, coherent, cooperative and well oriented to time ,place and person

Patient was moderately built and well nourished

No pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy

Vitals:

Temp - afebrile

RR - 18/ min

Bp - 140/ 100

PR - 82

Systemic examination:

CVS - S1 and S2 heard , no murmurs

CNS - Normal

RAS - BAE +

P/A - Soft non tender

Provisional diagnosis:

Fever with AKI on CKD secondary to urosepsis with antral gastritis and with moderate lumbar canal stenosis L3 toL4.

Investigations:

Treatment:

7/6

Inj neomol 1gm iv stat

Iv fluids 75 ml/hr

Inj HAI S/C

Inj monocef 1gm IV/BD

Inj PAN 40 mg iv/bd

8/6

IV fluids NS/RL @ 100 ml / hr

Inj monocef 1gm IV/BD

Inj PAN 40 mg IV/OD

Tab DOLO 650 mg PO/TID

9/6

IV fluids NS/RL @ 100 ml / hr

Inj monocef 1gm IV/BD

Inj PAN 40 mg IV/OD

10/6

Inj monocef 1gm IV/BD

Inj PAN 40 mg IV/OD

Tab DOLO 650 mg PO/TID