General medicine case discussion

B.Varshitha 
5th semester 
Roll no.21
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

A 65year old female patient came to hospital with cheif complaints of shortness of breath,decreased urine output and abdominal distension since 1week.

History of present illness 
Patient was apparently asymptomatic 20days back then she developed fever and decreased urine output for 5days for which she went to the local hospital and fever got subsided after treatment and patient was asymptomatic for 4days following which she developed SOB and abdominal distension associated with decreased urine output over 5days for which she went to the local hospital and her creatinine levels were increased and she was kept on foley's catheter they were discharged after symptoms were relieved and 3days back she again developed SOB and abdominal distension for which they when to local hospital and they referred to KIMS hospital for dialysis and abdominal distension and SOB.

History of past illness 
Patient has intermittent joint pains(yearly once)pain subsided after she took injections by local RMP doctor when pain appeared.

Past history 
Known case of HTN and diabetes since 3years and she is on medication 
No history of asthma epilepsy CAD 

Personal history 
• Diet : mixed
• Appetite: lost
• Sleep : adequate 
• Bowel habits: normal 
• Bladder habits : decreased urine output 
• Addictions:  Chronic alcoholic and smoker     since 25years

Family history 
No history of HTN epilepsy TB asthma CAD


Physical examination 

General examination 
• No pallor
• No icterus
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished.
• Mild bilateral pedal edema 

Vitals
Temperature: 98.4°F
Pulse rate:88/min
BP:90/70
RR:18/min
SPO2:98%


SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN

Distended abdomen
No tenderness
No palpable mass
free fluid present
No briuts
No palpable spleen and liver
Bowel sounds-yes
CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness.
Sensory system- Normal
Motor system- normal

PROVISIONAL DIAGNOSIS: ASCITES 

INVESTIGATIONS
CBP,LFT,CUE,RFT,ECG



Ultrasound report 
18/06/2022
ADTT: 34 secs 
Random blood sugar :126mg/dl
Blood Urea: 170mg/dl

CUE : normal 
Albumin +
ESR : 100mm

Hemogram
Hb 12.3
TLC: 18,900
N : 85
L : 7
E : 2
M : 6
B : 0
pH : 6.6
RBC : 4.56

LFT
ALT : 99
Total bilirubin : 1.95
Direct bilirubin : 0.43
SGOT : Normal 
SGPT : Normal 
Total protein : 5.9
Albumin : 2.7
A/G : 0.84
INR : 1.2
Serum creatinine: 3.2 mg/dl
Na : 133mEq/l
K   : 4.3mEq/l 
Cl  : 101mEq/l

20/06/2022
Hemogram 
Hb:12
TLC: 19,800
N : 79
L : 10
E : 3
M : 2
B : 0
pH : 5.95
RBC : 4.63


Blood urea : 195
Creatinine: 3.2
Na : 129mEq/l
K   : 4.3mEq/l 
Cl  : 103mEq/l

21/06/2022
Blood urea : 169
Hb : 11.6
TLC : 16,600
pH : 5.54
Serum creatinine: 2.5
Serum electrolytes 
Na : 134
K   : 3.8
Cl  : 102

Ascitic fluid : 
Sugar : 65mg/dl
Protein : 4.3g/dl
Amylase : 333IU/l
SAAG: 0.1
Serum albumin : 0.7g/dl
Ascitic albumin : 2.6 
Serum Amylase : 584
Serum lipase : 289
Spot urine protein : 10
Spot urine creatinine :10.7
Ratio: 0.07
Urine Na : 106
K : 171
Cl : 162




Treatment 

18/06/2022

IVF 1UNIT NORMAL SALINE @30ML/HOUR
INJ LASIX 20MG IV TWICE DAILY 
TAB ALDACTONE 25 MG ORALLY ONCE DAILY 
PROTEIN POWDER 2 SCOOPS IN GLASS OF MILK PER ORALLY THRICE DAILY 
INJ MONOCEF 1GM IV TWICE DAILY 
INJ PAN 40MG IV ONCE DAILY BEFORE BREAKFAST 
INJ ZOFER 4MG IV SOS
INJ HAI S/C THRICE DAILY 

19/06/2022

IVF 1UNIT NORMAL SALINE @30ML/HOUR
INJ PAN 40MG IV ONCE DAILY BEFORE BREAKFAST 
INJ ZOFER 4MG IV SOS
TAB LASIX 20MG ORALLY TWICE DAILY 
TAB TAXIM 1GM IV TWICE DAILY 

20/06/2022

INJ CEFTRIAXOME 2MG IV THRICE DAILY 
INJ PANTAC 50MG IV ONCE DAILY 
INJ LASIX 20MG IV TWICE DAILY 
INJ TRAMADOL 2 AMPULES SOS 
IVF I UNIT NORMAL SALINE @30ML/HOUR










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