05 Neeha sruthi
GENERAL MEDICINE
NEEHA SRUTHI
05(old batch 3rd semester)
BIMONTHLY ASSIGNMENT-JULY
I have been given the following assignment in an attempt to read, comprehend,analyze, reflect upon and discuss captured patient centered data.
This is the link of the questions and regarding the cases:
Question:1
Competency tested for peer to peer review and assignment:
CASE DETAILS:
Above case is about,A 55 year old female patient, a resident of Miryalaguda and farmer by occupation came to the hospital on 17/5/21 with the chief complaints of shortness of breath, pedal edema and facial puffiness.
Review about given case:
1.The given identified data by her clearly shows the appropriate diagnosis of Acute exacerbation of COPD.
2.She has appropriately provided the history,chief complaints,systemic examination,investigation,her diagnosis and treatment.
3. She has also given all the information about every aspect of the case which clearly shows the diagnosis of the right heart failure and bronchiectasis.
4.She has given the correct treatment to the patient.
5.All over she has totally given a complete layout of case very informatively.
Question:2
Link the Elog you made this month
Question:3
Again a kind of peer review but this time of the renal failure cases that have been linked in the assignment.
Patients with low back ache and renal failure:
CASE DETAILS:
The above linked case is about ,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:
POSTIVES:
1.The general information of the patient's chief complaints,history of illness and treatment history are very clear and informative.
2.She has examined the patient with both general and systemic examination which clearly shows keen position of the patient.
3.The investigations of Random blood sugar and complete urine examination with attested report is appropriately provided.
NEGATIVES:
1.No clear information of diagnosis.
CASE 2: ACUTE ON CKD
http://srinaini25.blogspot.
CASE DETAILS:
The above linked case is detailed about, a 75yr old male patient ,labourer by occupation ,came to casuality with Cheif complaints of
• 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.
NOTE:This case has been shifted to Orthopaedic department after 22/7/21 for further treatment.
CASE REVIEW:
POSITIVES:
1.She has appropriately mentioned the case details by mentioning from when patient is suffering,and by what means he is suffering with lower backache from 10 days.
2.As mentioned in case patient is also suffering from fever, cough,cold,chest pain,palpitations and sweating, this information show that she had took the case in clear and generalised manner.
3.The good thing of the case is she has examined all the aspects of the systemic examination like CVS,Respiratory,Abdominal,CNS.
4.The given reports are very clear and shows all the information to the person who diagnose as this is an ongoing case.
5.The treatment started from 13th july to 22nd july are clearly mentioned in the case.
NEGATIVES:
No negatives found.
CASE 3: CKD
CASE DETAILS:
Above linked case is all about,a 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 vomiting's 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:
1.She has clearly mentioned the personal information of the patient by stating about her marital status, no.of children,her daily work,and even her childhood hood history.
2.Menstrual history, obstetric history,birth history are very well generalised in the case.
3.Patient's vitals from day to day and systemic examination are performed well.
4.Investigations through blood test of vitamins,iron,hemogram etc,are prioritised well in the case.
NEGATIVES:
No negatives found.
CASE 4:Patient with coma and renal failure.
CASE DETAILS:
The above linked case is,a case of a diabetic with breathlessness.
Patient was admitted to the hospital in the afternoon of 28th June,2021.
"Chief 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.
CASE REVIEW:
POSITIVES:
1.The history she has mentioned shows that patient is diagnosed with Type-2 diabetes 3 years back and the appreciable part is she has noted each and every personal history information of the patient which can be referred for diagonosis.
2.Intubation and CPR are well written and also the family history and medical,and drug history.
3.General examination, vitals,and systemic examination of respiratory and CVS,abdominal,CNS are performed well, and the 2D ECHO report containing video shows the clear picture of functioning of heart.
4.Complete examination of all required tests and collective pictures of bed sores are clear and complete diagnosis was done.
5: Treatment was appropriate.
NEGATIVES:
No negatives are found.
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:
1.She has given the complete overall glance of the patient's present illness history, through looking to the case she also mentions that patient has presented to the casualty 15 days back.
2.She clearly mentions that the patient was diagnosed with Alcoholic Liver Disease,AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy,Hepatic encephalopathy grade 2.
3.Her general examination shows that patient also having icterus and pedal edema.
4.On over all the case details with examinations,investigations,
provisional diagnosis,final diagnosis,treatment,history and reports are well attached in the case sheet.
NEGATIVES:
No negatives found.
CASE 6:Patient 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:
POSITIVES:
1.Patient's present illness and history are taken appropriately and published correctly.
2.She has also mentioned all the information with dates and diagnosis done in history.
3.Appreciably given all the info of the case with all history,reports,examinations,diagnosis and treatment.
NEGATIVES:
No negatives found.
CASE 7:Patient with acute on CKD
CASE DETAILS:
The above linked case tells that,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:
1.The patient past history tells us that 2 years back he has been diagnosed for chronic renal failure.and also 7 months back due to heart failure he was treated with angiogram,2 months back with shortness of breath and 1 week back when case taken again shortness of breath grade-2. This all information tells that she has gone through the case very clearly.
2.The past history,drug history,personal history,general examination,vitals,all the systemic examinations are well published in the case.
3.Investigations,functional tests,provisional diagnosis and treatement with all the reports are observed clearly.
NEGATIVES:
No negatives found.
CASE 8:Patient with acute on CKD
CASE DETAILS:
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 vomiting and loose stools 5 days ago
- Lasted 3 days and subsided
CASE REVIWES:
POSITIVES:
1.She mentions here that patient was apparently asymptomatic 15 years back but she use to suffer with shortness of breath minimum 10 to 15 times per year which is a serious condition,this all information shows that she has been gathered all needed information of patient's history.
2.All her reports are very clear and also states that facing pedal edema since 3 days.
3.Patient's present complaints and tablets used in past are also noted in the case.
4.She has also mentioned the tests done for the patient after admission in our hospital.
5.Her reports,investigations,examinations,pictures,fever chart,and treatment are given.
NEGATIVES:
1.Diagnosis information needed.
CASE 9:Patient with AKI
CASE DETAILS:
The above mentioned case shows that,a 43 yr old male,resident of Nalgonda came to casualty with chief Complaints of;
⛤Loose Stools Since 20 days
⛤Pedal Edema Since 20 days
⛤Abdominal distension since 20 days
CASE REVIEW:
POSITIVES:
1.She tells that this case is regarding to alcoholic hepatitis and aki sec to gastroenteritis tells the patients present,past,and personal history.
2.The general examination of bilateral pitting edema,vitals,pre abdomen examination with inspection,palpation,percussion,auscultation,CVS,CNS,RS,these all information was appropriately mentions by her.
3.She has given all the investigation reports,x-ray,day to day treatment and diagnosis listed.
NEGATIVES:
1.Discharge sheet not provided.
CASE 10:Patient with AKI
CASE DETAILS:
Above shown case tells,a 60 year old female presented the OPD with chief complaints of:
*Pedal edema since 10 days
*Fever since 10 days.
CASE REVIEW:
POSITIVES:
1.She totally presents all information about the patients present,past,personal history,
2.She also mentioned clearly that pitting type pedal edema was identified in general examination.
3.She also examined all the major systems of the body in systemic examination part.
4.Her investigation order from urine examination to,blood picture, CBP, cardiac examination,blood sugars levels at all times,bacterial culture test are very well attested.
NEGATIVES:
No negatives found.
CASE 11:Patient 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:
1.Mentioned all the history of the patient in clear way.
2.She also states that patient is facing pedal edema with pitting type,icterus,cyanosis in her general examination.
3.Investigations are all provided.
NEGATIVES:
1. No negatives found but needed clear saying of diagnosis and treatment.
QUESTION 4:
Patient with low backache and renal failure:
CASE 1:AKI
COMPLAINTS:
- week back , after weight lifting
- Patient had sudden onset of pain in 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
http://srinaini25.blogspot.
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
• 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
https://krupalatha54.blogspot.
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
- 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
https://pallavi191.blogspot.
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
- 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:Patient with acute on CKD
https://kavyasamudrala.
COMPLAINTS:
- 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
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
https://krupalatha54.blogspot.
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:
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:Patient With AKI
https://keerthireddy42.
COMPLAITS:
- 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 SYNDROM
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
COMPLAINTS:
- 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
http://chavvaclassworkdecjan.
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:
The Elog pattern of learning ,case taking and dealing with every aspect of the case is very usefull for our medical practices.By now i have learned almost everything like how to deal with the patients,history taking,knowing their chief complaints,applying the correct investigations and examinations,and finally diagnosis and treatment.
I am happy that GENERAL MEDICINE department has been with us with each and every case,and they guided us very well.
This case taking is very important for our professional and personal life.
THANKYOU
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