GENERAL MEDICINE E-LOG

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT:

A 45 year old female, farmer by occupation, came to the opd with chief complaints of 

• Abdominal pain since 4 days
• Vomitings since 4 days 
• Head ache since 1 day

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back, then around 7:30 pm on wednesday patient alleged to be bitten by snake (? Viper) on right foot and was taken to the local hospital within 1 hour.

AVS was taken. She was fine for 1 day and then had complaints of swelling of right lower limb for which she went to the local hospital and an ointment was advised, then the swelling subsided. 

Patient has had abdominal pain since 4 days which is of Squeezing type, in periumbilical region, agg. by vomiting, No radiation. Abdominal distension was present after food consumption. She also had vomitings( 2-3 episodes/day, bilious, Not blood tinged). She has also had headache since 1 day, which was relieved with medication.

No c/o chest pain, Palpitations, Syncopal attacks.

No c/o Shortness of breath, Orthopnea, PND.

No c/o Burning micturition

No c/o Pedal edema, Facial puffiness, Decreased urine output.

HISTORY OF PAST ILLNESS:

Not a k/c/o DM, Hypertension, Asthma, TB, Epilepsy

TREATMENT HISTORY:

 No relevant treatment history.

PERSONAL HISTORY:

• Appetite is normal
• Having Mixed diet( Non vegetarian)
• Constipation( once every 2-3 days)
• Micturition- Normal
• No other habits/ addictions.

GENERAL EXAMINATION:

Patient is conscious.

Pallor is present.

Absence of Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Pulse rate: 96 beats per min

2.Respiratory rate: 24 cycles per min

3.BP: 150/90 mm Hg

4.SpO2: 99% @ Room air 

5.GRBS: 180mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No murmurs
• No thrills

RESPIRATORY SYSYTEM:

• No dyspnoea
• No wheezing
• Position of trachea is central
• Normal vesicular breath sounds

EXAMINATION OF ABDOMEN:

• Shape- Scaphoid
• Tenderness in periumbilical region
• No palpable mass
• No free fluid 
• No bruits
• Liver is not palpable
• Spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient is conscious
• Speech is normal
• No signs of Meningeal irritation 

PROVISIONAL DIAGNOSIS:

Acute Kidney Injury Secondary to acute tubular necrosis, snake bite, ? Toxinemia

                                           

INVESTIGATIONS:

Investigation on 2/8/21:

                                   

ECG

Investigations on 3/8/21:

                              

Chest X-ray 

Urine Sodium

Blood Urea

Serum Electrolytes

Serum creatinine 

Urine Protein/Creatinine ratio

CUE

Investigations on 5/8/21:

                               

RFT

LFT:

T.B - 1.0mg/dl

D.B - 0.2mg/dl

I.B - 0.8mg/dl

ALP - 90IU/L

TP - 6.7gm/l

A - 4.5gm

G - 2.2gm

SGPT - 34IU/L

SGOT - 24IU/L

Investigation on 6/8/21:

                            

Hemogram

Previous Investigation on 2/7/21:

                              

Ultrasound report

TREATMENT:

1. IVF - 20NS 100ml/hr

            20RL 100ml/hr

2. Inj. PAN 40mg IV/OD

3. Inj. ZOFFER 4mg /IV/TLD

4. Inj. BUSCOPAN IM/BD

5. BP/PR/RR/SpO2 4th hrly

6. GRBS CHARTING 6th hrly

7. STRICT I/O CHARTING 

8. TAB. PCM 650mg/PO

9.Inj. LASIX 40mg IV/BD if SBP> 100mm Hg