04 Srilasya akula

E-LOGS GENERAL MEDICINE

Hi , I'm lasya akula , a medical student(3rd sem)

"This is 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 patients clinical problems with collective current best evidence based inputs"

This also reflects patient centered care and online learning portfolio. Hope this will be informative ! 

This e-log is made under the guidance of  Dr.suhas .

SRILASYA AKULA

04

3rd sem 

Case history: A 42 year old male patient came to casuality with chief complaints of b/l pedal oedema (pitting type)(l>r) since 15 days.

Date of admission : 1/7/21

HISTORY OF PRESENTING ILLNESS :

 

Ulcer over left malleoli 10 days back 

Got treatment in local hospital .

Fever:- low grade intermittent , generalised weakness and sob grade 2-3 since 2 days.

No h/o pain abdomen, vomiting, loose stools

No h/o cough, chest pain

No h/o decreased urine output/ burning mictiurition and no other complaints 

PERSONAL HISTORY :

Patient consumes 180ml of alcohol per day and khaini 2-3 per day since 20 years 

HISTORY OF PAST ILLNESS :

Not k/c/o dm, htn, asthma, epilepsy, cad, tb 

GENERAL EXAMINATION :

conscious and coherent

Icterus, pedal oedema present.

No pallor, cyanosis, clubbing, lymphadenopathy 

VITALS :

Temperature:- 98.6°F

PR: 110/min

RR: 18/ min

BP: 100/70 mm Hg

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM  :

Apex beat : visible

Diffuse shifted down and out 

Palpable p2+

Parasternal heave + (grade 3)

S1 , S2 + , no murmurs

RESPIRATORY SYSTEM :

Barrel shaped chest 

BAE+

Crepts + right sided lung fields

                                           

 

ABDOMINAL EXAMINATION :soft , no tenderness.

CENTRAL NERVOUS SYSTEM : No focal neurological deficits .

PROVISIONAL DIAGNOSIS :  

HFref 2° to ?CAD    b/l pleural effusion

AKI ( ? prerenal )    CRS -1 

? Alcoholic liver disease 

R. Lower lobe pneumonia 

 LL Cellulitis  

He's also had non STEMI on 2/7/21 i.e 2nd day of admission. 

INVESTIGATIONS : PATHOLOGICAL AND BIOCHEMICAL .

1/7/21:

Hemogram:

•hb - 10.3

•TC-19,400

•neutrophils-92

•lymphocytes-04

•eosinophils-01

•monocytes-03

•basophils-00

•PCV-30.9

•MCV-72.4

•MCHC-33.3

•RDW-CV-15.3

•RDW-SD-40.2

•RBC count :4.27

•platelet count:4.27

CUE:

• colour   :   pale yellow
• appearance: clear
• reaction  :  acidic
• specific gravity:  1.010
• albumin :   positive
• sugar:  nil
• bile salts : nil
• bile pigments : nil
• pus cells   : 4 to 6
• epithelial cells :  2 to 3
• RBC     : nil
• crystls : nil
• casts  : nil
• amorphous deposits - nil

• serum creatinine - 2.1
• blood urea          -81

LFT:

• total bilirubin - 2.6
• direct bilirubin -1.35
• SGOT             75
• SGPT              31
• ALP                157
• TP                   6.1
• albumin           3.5
• A/G                 1.37  

SERUM ELECTROLYTES :

• sodium-129
• potassium-4.8
• chloride-97         

ECG:

7/7/21

CXR :

TREATMENT :  

For cellulitis : 

azithromycin and ceftriaxone

Magnesium sulphate dressings 

Lower limb elevation 

B/l venous Doppler to rule out dvt

Treatment on 2/7/21: 

1)Fluid restriction   <1Lit / day 

2)Salt restriction <2gm /day 

3)Injection ceftriaxone  1gm IV /BD

4) Tab LASIX 40mg BD ( 8am to 4pm) 

5) Tab MET-XL 12.5 mg BD

6) BP PR temp spO2 monitoring 

7) Tab AZITHROMYCIN 500mg OD 

8) Tab ECOSPIRIN av 75/20 mg OD

treatment on 3/7/21 :

1)Fluid restriction <1Lit / day 

2)Salt restriction <2gm /day 

3)Injection ceftriaxone 1gm IV /BD

4) Tab LASIX 40mg BD ( 8am to 4pm) 

5) Tab MET-XL 12.5 mg BD

6) BP PR temp spO2 monitoring 

7) Tab AZITHROMYCIN 500mg OD 

8) Tab ECOSPIRIN av 75/20 mg OD

Treatment on 4/7/21: 

1)fluid restriction <1lit/day 

2)salt restriction. <2gm/day 

3) inj ceftriaxone 1gm IV/BD 

4)tab LASIX 40mg BD (8am to 4pm)

5) Tab MET-XL 25mg BD 

6) Tab AZITHROMYCIN 500mg OD

7)Tab ECOSPIRIN av 75/20 mg OD

8)BP PR temp and spO2 monitoring 

9) tab DIGOXIN 0.25 mg stat 

Treatment on 5/7/21 : 

1)fluid restriction <1lit/day 

2)salt restriction. <2gm/day 

3) inj ceftriaxone 1gm IV/BD 

4)tab LASIX 40mg BD (8am to 4pm)

5) Tab MET-XL 25mg BD 

6) Tab AZITHROMYCIN 500mg OD

7)Tab ECOSPIRIN av 75/20 mg OD

8)BP PR temp and spO2 monitoring

9) tab DIGOXIN 0.25 mg stat 

Treatment on 6/7/21 :

1)fluid restriction <1lit/day 

2)salt restriction. <2gm/day 

3) inj ceftriaxone 1gm IV/BD 

4)tab LASIX 40mg BD (8am to 4pm)

5) Tab MET-XL 25mg BD 

6) Tab AZITHROMYCIN 500mg OD

7)Tab ECOSPIRIN av 75/20 mg OD

8)BP PR temp and spO2 monitoring

9) tab DIGOXIN 0.25 mg stat 

10) inj .CLINDAMYCIN 600mg IV/TID .

treatment on 7/7/21 : 

1)fluid restriction <1lit/day 

2)salt restriction. <2gm/day 

3) inj ceftriaxone 1gm IV/BD 

4)tab LASIX 40mg BD (8am to 4pm)

5) Tab MET-XL 25mg BD 

6) Tab AZITHROMYCIN 500mg OD

7)Tab ECOSPIRIN av 75/20 mg OD

8)BP PR temp and spO2 monitoring

9) tab DIGOXIN 0.25 mg stat 

10) inj .CLINDAMYCIN 600mg IV/TID .

 More About cellulitis :

•https://www.everydayhealth.com/cellulitis/signs-symptoms-diagnosis/

•https://journalofethics.ama-assn.org/article/cellulitis-definition-etiology-diagnosis-and-treatment/2006-12

THANK YOU