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medicine case

 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

 A 79yr male presented to casuality with chief complaints of 
pedal edema  since 10 days ,
shortness of breath since 5 days

  Patient was apparently asymptomatic 10days back then came with c/o   Pedal edema since 10 days -pitting type ,shortness of breath since 10 days insidious in onset , grade 3(marked limitation in activity) ,Fever 7  days back which subsided ,Dry cough 7 days back which subsided.

PAST HISTORY-
K/c/o hTN since 10 yrs on  regular medication-telmisartan 40mg
H/o CVA 10 yrs back for which he was treated. 
Not a k/c/o diabetes , TB,asthama,cvd , epilepsy.
PERSONAL HISTORY-
Diet - mixed
Appetite - normal
Bowel ,bladder movements - regular
Sleep - adequate 
Addictions - h/o of smoking  and alcohol, stopped 10yrs back.
FAMILY  HISTORY- Not significant 

GENERAL  EXAMINATION -
Patient is conscious, , coherent, cooperative   oriented to time,  place, person 
Vitals on DOA:
Bp  110/80 
,PR- 90 , 
GRBS -141,
RR-26,
SPo2- 98
No pallor 
No cyanosis
No clubbing
No icterus ,
No Lymphadenopathy 
SYSTEMIC EXAMINATION -
CVS:
S1 S2 heard no murmurs
RESPIRATORY SYSTEM:
BAE +
NVBS+
Trachea is central
Adventitious sounds- B/L infraaxillary crepts L>R
 PER ABDOMEN:
Shape of abd - scaphoid
Tenderness  -not present
Bowel sounds - present
No palpable mass, fluid , bruit
CNS:
Patient is conscious , speech normal, no meningeal signs
Cranial nerve ,Sensory, motor examination ,reflexes , gait-  normal , no cerebral signs

INVESTIGATIONS :
On 20 /6/21


TREATMENT:
On 20/6/21
Inj Lasix 80mg iv Stat followed by inj Lasix 5ml iv infusion
Fluid restriction <1.5L/day
Salt restriction <4gm/day
Inj PAN 40mg iv/OD
Inj optineuron 1 Amp IM/OD
Daily weight monitoring 
Struct I/O monitoring 
BP ,PR ,Spo2  monitoring hourly
Inj thiamine 1amp in 100ml NS IV TID
Tab ecospirin av 75/20mg
Inj ceftrioxone 1gm iv /bd


On 21/6/21: 
On 21/06/21
Inj Lasix stopped
Inj thiamine 1amp in 100ml NS IV OD
Inj ceftrioxone 1gm iv /bd
Inj PAN 40mg iv/OD
Inj optineuron 1 Amp IM/OD
Tab ecospirin av 75/20mg
Daily weight monitoring 
Struct I/O monitoring 
BP ,PR ,Spo2  monitoring hourly
Fluid restriction <1.5L/day
Salt restriction <4gm/day

On 22/06/21
TREATMENT:
Inj thiamine 1amp in 50ml /NS/IV/OD
Inj augmentin  1.2g IV/BD
Tab azithral 500mg PO/OD
Inj Piptaz 4.5 gm IV stat, inj piptaz 2.25gm /iv
Salt restriction <4gm/day
Inj optineuron 1 amp/IM /OD
Tab ecospirin AV (75/20) PO/OD
Strict I/O monitoring 
BP ,PR,Spo2 monitoring hourly 

On 23/06/21
TREATMENT:
on 23/06/21
Inj piptaz 2.25gm IV/TID
Inj PAN 40mg IV /OD
Inj optineuron IM/OD
Levoflox 750mgPO/OD
Zolfresh 5mg PO/HS
Tab ecospirin av 75/20 PO/OD
Salt restriction <4gm/day
Strict temperature monitoring 
Strict I/O monitoring 
Strict BP,PR,SpO2  monitoring 

On 24/06/21
TREATMENT:
Inj piptaz 4.5gm IV/TID
Inj PAN 40mg IV /OD
Inj optineuron 1amp in 100ml NS IV/OD
Levoflox 750mgPO/OD
Zolfresh 5mg PO/HS
Tab ecospirin av 75/20 PO/OD
2 egg whites per day
Strict temperature monitoring 4rth hourly 
Strict BP, PR charting 2 hourly
Strict I/O monitoring daily
Tab sporlac ds P/O TID
No additional iv fluids apart from 200ml NS  for optineuron 

25/6/21
TREATMENT:
Inj piptaz 4.5gm IV/TID
Inj PAN 40mg IV /OD
Inj optineuron 1amp in 100ml NS IV/OD
Levoflox 750mgPO/OD
Zolfresh 5mg PO/HS
Tab ecospirin av 75/20 PO/OD
Tab pcm 650mg PO/TID
2 egg whites per day
Strict temperature monitoring 4rth hourly 
Strict BP, PR charting 2 hourly
Strict I/O monitoring daily


26/06/21
TREATMENT:
Inj pitaz 4.5gm IV/TID 
Tab levofloxacin 750mg PO/OD
Inj PAN 40mg IV /OD
Inj optineuron 1amp in 100ml NS IV/OD
Tab ecospirin av 75/20 PO/OD
Tab pcm 650mg PO/TID
Tab allegra 120mg PO/OD
Inj Heparin 1ml in 49ml NS @10ml /hr
2 egg whites per day
Strict temperature monitoring 4rth hourly 
Strict BP, PR charting 2 hourly
27/06/21:
TREATMENT:

Inj pitaz 4.5gm IV/TID 
Tab levofloxacin 750mg PO/OD
Inj PAN 40mg IV /OD
Inj optineuron 1amp in 100ml NS IV/OD
Tab ecospirin av 75/20 PO/OD
Tab pcm 650mg PO/TID
Tab allegra 120mg PO/OD
2 egg whites per day
Strict temperature monitoring 4rth hourly 
Strict BP, PR charting 2 hourly


DISCHARGE SUMMARY :28/06/21

Name of Treating Faculty
DR.ARJUN KUMAR(ASST PROF)
DR.AJITH KUMAR(PGY2)
DR.DURGA KRISHNA(PGY1)
DR.KEERTHI(INTERN)
DR.SREEJA(INTERN)
DR.SRIYA(INTERN)
DR.VAISHNAVI(INTERN)
DR.SHREYA(INTERN)
Case History and Clinical Findings
A 79yr male presented to casuality with chief complaints ofpedal edema since 10 days ,shortness of breath since 5 days. Patient was apparently asymptomatic 10days back then came with c/o Pedaledema since 10 days -pitting type ,shortness of breath since 10 days insidious in onset , grade 3(marked limitation in activity) ,Fever 7 days back which subsided ,Dry cough 7 days back which subsided. PAST HISTORY-K/c/o hTN since 10 yrs on regular medication-telmisartan 40mg
H/o CVA 10 yrs back for which he was treated.
Addictions - h/o of smoking and alcohol, stopped 10yrs back.
Investigations:20/06/21
BLOOD UREA -42 mg/dl
SERUM CREATININE-1.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 
 SODIUM-135 mEq/L
 POTASSIUM-4.6 mEq/L
 CHLORIDE-100 mEq/L
 COMPLETE URINE EXAMINATION (CUE) 
 COLOUR-Pale yellow
 APPEARANCE-Clear
 REACTION-Acidic
 SP.GRAVITY-1.010
 ALBUMIN-trace
 SUGAR-Nil
 BILE SALTS-Nil
 BILE PIGMENTS-Nil
 PUS CELLS: 3-4
 EPITHELIAL CELLS:2-3
 RED BLOOD CELLS -Nil
 CRYSTALS-Nil
 CASTS-Nil
 AMORPHOUS DEPOSITS-Absent
 OTHERS-Nil
21-06-2021
 SERUM ELECTROLYTES (Na, K, C l)  
 SODIUM-130 mEq/L
 POTASSIUM-4.7 mEq/L
 CHLORIDE-101 mEq/L
HBsAg-RAPID-Negative
Anti HCV Antibodies- RAPID :Non Reactive Kit

 COMPLETE BLOOD PICTURE (CBP)
 HAEMOGLOBIN-10.0 gm/dl
 TOTAL COUNT: 22100 cells/cumm
 NEUTROPHILS-39 %
 LYMPHOCYTES-18 %
EOSINOPHILS-35 %
 MONOCYTES-08 %
 BASOPHILS-00 %
 PLATELET COUNT-2.0
 SMEAR:
Normocytic normochromic anemia with  leucocytosis and eosinophilia
 ABG 
 PH- 7.41
 PCO2-20.9
 PO2-55.4
 HCO3-13.2
 St.HCO3-16.5
 BEB-9.7
 BEecf-10.5
 TCO2-27.7
 O2 Sat-89.5
 O2 Count-11.9

SERUM PROTEIN - 4.5 g/dl  
 COMPLETE URINE EXAMINATION :
 COLOUR-Pale yellow
 APPEARANCE-Clear
 REACTION-Acidic
 SP.GRAVITY-1.010
 ALBUMIN-Nil
 SUGAR-Nil
 BILE SALTS-Nil
 BILE PIGMENTS-Nil
 PUS CELLS-2-3
 EPITHELIAL CELLS-2-3
 RED BLOOD CELLS -Nil
 CRYSTALS-Nil
 CASTS-Nil
 AMORPHOUS DEPOSITS-Absent
 OTHERS-Nil
 SERUM ELECTROLYTES (Na, K, C l) 
 SODIUM-133 mEq/L
 POTASSIUM-4.6 mEq/L
 CHLORIDE-99 mEq/L
25-06-2021
 ABG 
 PH-7.44
 PCO2-22.8
 PO2-78.7
 HCO3-15.4
 St.HCO3-18.9
 BEB-6.8
 BEecf-8.0
 TCO2-30.8
 O2 Sat-95.4
 O2 Count-16.3
26-06-2021
SARS-COV-2
Qualitative PCR  -Negative
27-06-2021 
 COMPLETE URINE EXAMINATION (CUE) 
 COLOUR-Pale yellow
 APPEARANCE-Clear
 REACTION-Acidic
 SP.GRAVITY-1.010
 ALBUMIN-Nil
 SUGAR-Nil
 BILE SALTS-Nil
 BILE PIGMENTS-Nil
 PUS CELLS-2-3
 EPITHELIAL CELLS-2-3
 RED BLOOD CELLS -Nil
 CRYSTALS-Nil
 CASTS-Nil
 AMORPHOUS DEPOSITS-Absent
 OTHERS-Nil

Treatment Given:
On 20/6/21
Inj Lasix 80mg iv Stat followed by inj Lasix 5ml iv infusionFluid restriction <1.5L/daySalt
restriction <4gm/dayInj PAN 40mg iv/ODInj optineuron 1 Amp IM/ODDaily weight monitoringStruct I/O
monitoringBP ,PR ,Spo2 monitoring hourlyInj thiamine 1amp in 100ml NS IV TIDTab ecospirin av 75/20mgInj ceftrioxone 1gm iv /bd
On 21/06/21
Inj Lasix stoppedInj thiamine 1amp in 100ml NS IV/ODInj ceftrioxone 1gm iv /bdInj PAN 40mg iv/ODInj optineuron 1 Amp IM/ODTab ecospirin av
75/20mgDaily weight monitoringStruct I/O monitoringBP ,PR ,Spo2 monitoring hourlyFluid restriction<1.5L/daySalt restriction <4gm/day
ON 22/06/202
1Inj thiamine 1amp in 50ml /NS/IV/ODInj augmentin1.2g IV/BDTab azithral 500mg PO/ODInj Piptaz 4.5 gm IV stat, inj piptaz 2.25gm /ivSalt restriction<4gm/dayInj optineuron 1 amp/IM /ODTab ecospirin AV (75/20) PO/ODStrict I/O monitoringBP,PR,Spo2 monitoring hourly
on 23/06/21
Inj piptaz 2.25gm IV/TIDInj PAN 40mg IV /ODInj optineuronIM/ODLevoflox 750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODSalt restriction<4gm/dayStrict temperature monitoringStrict I/O monitoringStrict BP,PR,SpO2 monitoring
ON24/06/2021
Inj piptaz 2.25gm IV/TIDInj PAN 40mg IV /ODInj optineuron IM/ODLevoflox750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODSalt restriction <4gm/dayStrict temperature monitoringStrict I/O monitoringStrict BP,PR,SpO2 monitoring
ON 25/06/2021
Inj piptaz4.5gm IV/TIDInj PAN 40mg IV /ODInj optineuron 1amp in 100ml NS IV/ODLevoflox
750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODTab pan 650mg PO/TID2 egg
whites per dayStrict temperature monitoring 4rth hourlyStrict BP, PR charting 2 hourlyStrict I/O
monitoring daily
ON 26/06/2021Inj piptaz 4.5gm IV/TIDInj PAN 40mg IV /ODInj optineuron 1amp in
100ml NS IV/ODLevoflox 750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODTab pan650mg PO/TID2 egg whites per dayStrict temperature monitoring 4rth hourlyStrict BP, PR charting 2hourlyStrict I/O monitoring daily
ON 27/06/2021
Injpiptaz 4.5gm IV/TIDInj PAN 40mg IV /ODInj optineuron 1amp in 100ml NS IV/ODLevoflox
750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODTab pan 650mg PO/TID2 egg
whites per dayStrict temperature monitoring 4rth hourlyStrict BP, PR charting 2 hourlyStrict I/O
monitoring dailyTAB,ALLEGRA 120 MG PO/OD
 ON 28/06/2021Inj piptaz 4.5gm IV/TIDInj PAN 40mgIV /ODInj optineuron 1amp in 100ml NS IV/ODLevoflox 750mgPO/ODZolfresh 5mg PO/HSTab ecospirin av 75/20 PO/ODTab pan 650mg PO/TID2 egg whites per dayStrict temperature monitoring
4rth hourlyStrict BP, PR charting 2 hourlyStrict I/O monitoring dailyTAB ALLEGRA 120MG PO/OD

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