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A Case of 50 yr old Female

This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

This E-log is presented under the guidance of Dr.Pallavi(intern).

A case of 50 yr old female with Left lower lobe consolidation 

Date of admission: 26/07/2021

CHIEF COMPLAINTS:
50 year old female came with complaints of 
▪︎Abdominal distension since 5 days  
▪︎Shortness of breath since 5 days  
▪︎Burning micturition since 5 days  
▪︎Decreased appetites, nausea since 5 days 
▪︎Dry cough since 1 day 


HISTORY OF PRESENTING ILLNESS:
▪︎Patient was apparently asymptomatic 2 years back, then diagnosed with pancreatitis and AKI, for which she underwent 2 sessions of hemodialysis.
At that time, she also tested positive for dengue.
▪︎2 months back, she tested positive for Covid 19 and received medication at home. 
▪︎She was also diagnosed to be diabetic and hypertensive, but on irregular medication.
▪︎Now, she came with C/o abdominal distension, decreased appetite, nausea, burning micturition and SOB on exertion (grade 2); for which she went to local hospital but her symptoms did not subside. So, she came here for better treatment.

No h/o palpitations, chest pain, fever, decreased urine output, pedal edema, orthopnea, PND, vomitings.

PAST HISTORY:
▪︎Not a k/c/o asthma, TB, epilepsy, CAD, CVA, thyroid disorders.
▪︎No h/o surgeries and blood transfusions in the past.

PERSONAL HISTORY:
▪︎She used to consume alcohol regularly. But she stopped 1½ year back.

FAMILY HISTORY:
No significant history 

GENERAL EXAMINATION: 
▪︎Patient is conscious, coherent, co-operative
▪︎Moderately built and nourished
▪︎No signs of pallor, icterus, cyanosis, clubbing, koilonychia generalized lymphadenopathy, edema.

Vitals @ the time of admission:
▪︎Temperature- 98.4°F
▪︎PR-104 BPM, regular
▪︎RR- 16 cpm
▪︎BP- 90/60, after 1 bolus of IVF - 110/60
▪︎SPo2 - 99% @ room temperature 
▪︎GRBS - 520 mg/dl

SYSTEMIC EXAMINATION: 
Per abdomen:
▪︎Abdomen is distended and soft
▪︎Diffuse tenderness present
▪︎No palpable masses
▪︎No free fluid
▪︎Hernial orifices - normal
▪︎Bowel sounds - heard

CVS:
▪︎S1, S2 Heard
No thrills, No Murmurs heard 

Respiratory system:
▪︎Trachea-Central
▪︎BAE present 
▪︎NVBS heard
▪︎Decreased breath sound on right side
▪︎Basal crepitations present 

CNS:
▪︎Speech - normal
▪︎No signs of meningeal irritation
▪︎Motor and sensory system: normal
▪︎Cranial nerves - intact
▪︎Reflexes - present
▪︎Plantar - flexor on both sides

INVESTIGATIONS:
           ULTRASOUND REPORT

                             ECG

                     HEMOGRAM

                          RT-PCR


                     CHEST X-RAY

PROVISIONAL DIAGNOSIS:
▪︎Left lower lobe consolidation
▪︎UTI
▪︎K/c/o of TYPE 2 DM with uncontrolled sugar level.

TREATMENT:

DAY-1 
•IVF NS @rate of 150 ml/hr
•GBRS hourly 
•INJ. 39ml NS with 40IU  HAI @ rate of 6ml/hr
•Strict IO Charting 

DAY-2
•INJ. PIPTAZ gm/IV/TID
•INJ. HAI SC/TID according to sliding scale
•INJ. PAN 40mg/IV/OD
•INJ. ZOFER 4mg/IV/OD
•GBRS Charting 4th hourly 
•Tab. ULTRACET PO/QID (½-½-½-½)

DAY-3
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ULTRACET PO/QID(½-½-½-½)
•SYP.ASCORIC ACID PO/TID 
•Nebulization with ASTHALIN 10ml PO/TID 
•Oral fluids 2-3 l/day 
•BP /PR Charting 4th hourly 

DAY-4
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ASCORIL 10ml/PO/TID
•TAB. ULTRACET PO/QID(½-½-½-½)
•Nebulization with ASTHALIN 6th hourly and BUDECORT 12th hourly

DAY-5
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ASCORIL 10ml/PO/TID
•TAB. ULTRACET PO/QID(½-½-½-½)
•Nebulization with ASTHALIN 6th hourly and BUDECORT 12th hourly


DISCHARGE SUMMARY:
▪︎Date of discharge: 30/07/2021
▪︎FACULTIES
Dr.Arjun
Dr.Aashitha
Dr.Vinay
Dr.Kusuma
Dr.Sameera
Dr.CVS Siddharth 
Dr.Pallavi
Dr.D Siddharth 

Diagnosis 
Pneumonia (Post Civid Sequele) with uncontrolled sugar with AKI resolved with k/c/o DM-2 since 2 yrs.

CASE HISTORY AND CLINICAL FINDINGS 
50 year old female came with complaints of abdominal distension, shortness of breath, burning micturition, decreased appetite, nausea since 5 days and dry cough since yesterday.

History of presenting illness
Patient was apparently asymptomatic 2 years back, then diagnosed with pancreatitis and AKI, for which she underwent 2 sessions of hemodialysis. At that time, she also tested positive for dengue.

2 months back, she tested positive for covid 19 and received medication at home. She was also diagnosed to be diabetic and hypertensive, but on irregular medication.

Now, she c/o abdominal distension, decreased appetite, nausea, burning micturition and sob on exertion (grade 2); for which she went to local hospital but her symptoms did not subside. So, she came here for better treatment.

No h/o palpitations, chest pain, fever, decreased urine output, pedal edema, orthopnea, PND, vomitings.

Past history
Not a known case of asthma, TB, epilepsy, CAD, CVA, thyroid disorders.
No h/o surgeries and blood transfusions in the past.

Personal history
She used to consume alcohol regularly. But she stopped 1½ year back.

Family history 
No significant history

General examination
Patient is conscious, coherent, co-operative

Moderately built and nourished

No signs of pallor, icterus, cyanosis, clubbing, koilonychia generalized lymphadenopathy, edema

Vitals at the time of admission:
•Temp - 98.4°F
•PR - 104 BPM, regular
•RR - 16 cpm
•BP - 90/60, after 1 bolus of IVF - 110/60
•Spo2 - 99% at room temperature 
•GRBS - 520 mg/dl

Systemic examination
Per abdomen:
Abdomen is distended and soft
Diffuse tenderness present
No palpable masses
No free fluid
Hernial orifices - normal
Bowel sounds - heard

CVS:
S1, S2 Heard
No thrills, Murmurs

Respiratory system:
Trachea - Central
BAE+
NVBS heard
Decreased breath sound on right side
Basal crepitations +

CNS:
Speech - normal
No signs of meningeal irritation
Motor and sensory system: normal
Cranial nerves - intact
Reflexes - present
Plantar - flexor on both sides

Investigations
HBA1C- 6.8%

Treatment 
DAY-1 
•IVF NS @rate of 150 ml/hr
•GBRS hourly 
•INJ. 39ml NS with 40IU  HAI @ rate of 6ml/hr
•Strict IO Charting 

DAY-2
•INJ. PIPTAZ gm/IV/TID
•INJ. HAI SC/TID according to sliding scale
•INJ. PAN 40mg/IV/OD
•INJ. ZOFER 4mg/IV/OD
•GBRS Charting 4th hourly 
•Tab. ULTRACET PO/QID (½-½-½-½)

DAY-3
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ULTRACET PO/QID(½-½-½-½)
•SYP.ASCORIC ACID PO/TID 
•Nebulization with ASTHALIN 10ml PO/TID 
•Oral fluids 2-3 l/day 
•BP /PR Charting 4th hourly 

DAY-4
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ASCORIL 10ml/PO/TID
•TAB. ULTRACET PO/QID(½-½-½-½)
•Nebulization with ASTHALIN 6th hourly and BUDECORT 12th hourly

DAY-5
•INJ.PIPTAZ 2.25gm/IV/TID
•IVF 20NS-75ml/hr 
•INJ.HAI SC/TID according to sliding scale 
•INSULIN 8AM N- 10U R-7U
                2PM R-7U
                8PM N-10U R-7U
•PAN 40 mg  PO/OD
•INJ. PAN 40mg IV/OD
•INJ.ZOFER 4mg IV/OD
•GRBS charting 4th hourly 
•TAB.ASCORIL 10ml/PO/TID
•TAB. ULTRACET PO/QID(½-½-½-½)
•Nebulization with ASTHALIN 6th hourly and BUDECORT 12th hourly








  
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