57/M with HTN since 4 months

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A 57 year old male patient with bilateral pedal edema

57 year old male farmer by occupation

Came with complaints of fever since 3 days

Patient was apparently asymptomatic 4 months back then he developed: 

Bilateral pedal edema, pitting type, insidious in onset, gradually progressive from ankle to below knee

H/o dcreased urine output

No h/o palpitations or burning micturition or chest pain.

C/o B/L knee pain since 4 months

Patient went to the outside hospital were renal function tests were done and he was found to have raised urea and creatinine levels

Patient was taken for dialysis (total of 4 dialysis were done), last session 10/12/21

He was diagnosed with hypertension at the same time and is on regular medication(Tab. NICARDIA 10MG)

Patient came to our hospital for dialysis and central line placement was tried but failed and hence patient was put on conservative management. 

H/o HTN since 4 months

N/K/C/O DM, TB, BA, Epilepsy

Appetite- normal

Bladder and bowel movements- regular

Patient takes alcohol (180ml 2-3 times/week)

Smokes beedi (2-3/day)

History of NSAID's abuse (takes tablets when he has knee joint pains)

O/E- pt is c/c/c

Bp- 130/80mmhg

Pr- 78 BPM

RR- 17cpm

CVS- S1 S2 heard

RS- BAE (+)

P/A soft, non tender

CNS- NFND

Reports as of 24/1/22 (outside reports)

1/2/22

S- c/o B/L knee pain no c/o fever

O- 

O/E- pt is c/c/c

Bp- 130/70mmhg

Pr- 80BPM

RR- 14cpm

CVS- S1 S2 heard

RS- BAE (+)

P/A soft, non tender

CNS- NFND

A-

NSAID Induced Nephropathy with hypertension

P- 

T. LASIX 20mg PO/BD

T. ULTRACET ½TABLET QID

29/M with fever and lower backache since 2 days

29 year old male came to casualty with complaints of fever and lower backache since 2 days.

Fever low grade, a/w chills and rigors, subsided on medication. Pain was dragging type, in lower back radiating to front.

Pt was apparently asymptomatic 1 year back, then presented to casualty with similar complaints along with decreased urine output hicupps and vomiting from 2 days, then developed involuntary movements of right lower limb for which he visited local hospital and on routine investigations was found to be hypokalemic, took some medication and the situation resolved. 6 months later he developed lower backache and investigations revealed renal calculi for which conservative management was done and complaints got resolved. then pt developed right sided involuntary movements again, went to local RMP, had 2 episodes of GTCS and referred to KIMS, NKP for further evaluation. Was diagnosed as ACUTE KIDNEY INJURY/NCC/TUBERCULOMA (2° seizures) and (in March of 2021) pt underwear 4 sessions of dialysis

NO H/O HTN,DM, TB,ASTHMA.CVA,CVD

OIE-PT CONCIOUS.COHERENT COOPRATIVE, GCS-15/15 

-NO SIGNS OF ICTERUS CYNOSIS.CLUBBING, LYMPEDEEMOATHY,GENERALISED EDEMA,

-VITALS-

BP. 140/BMMG PR.8ZBPM PR 18CPM.SPO2 98%AT ROOM AIR 

SYSTEMIC EXAMINATION -CVS-s1,82+ RS-BAE+ P/A-SOFT NON TENDER

55/F with sweating and low sugars

55 year old house wife came to casualty with complaints of:

Sweating and seizure like activity since 1½ hr, after insulin injection

Pt was apparently asymptomatic 10 years back then on routine checkup was told to have Diabetes Mellitus type 2 and advised to use Inj. Human Mixtard 15 units, twice a day. Dosage increased to 20 units one month back.

Pt had C/O polyuria, polydypsia and loose stools 1 month back. stools were watery consistency, non blood stained, 10 episodes per day for 3 days. Watery stools subsided on medication.

Last night pt consumed her meal, followed by s/c insulin injection. ½ hr later pt developed profuse sweating, cold to touch, clenching of fists, uprolling of eyes, frothing at mouth and loss of consciousness. 

Seizure like activity lasted ½ hr

Post ictal confusion (+)

Non responsive to verbal commands or touch stimulus

No H/O fever, burning micturition, cold

Pt was administered 2 IVF- 25 D, after that pt regained consciousness and no seizure episodes after that. 

K/C/O DM-Type2 since 10 years, on insulin

K/c/o HTN since 3 months, on regular medication

N/K/C/O TB, BA, CAD, CVA, thyroid disorders

Similar complaints, 4 episodes in the last 1 year, most recent being yesterday. 

H/o 4 hospital admissions for similar complaints in the past 10 years, duration of 4-10days, latest being 1 year back. 

Grbs on presentation- 11mg/dl in both hands

After stabilization- 168mg/dl

Pt is conscious

Bp- 180/90mmhg

PR-91 BPM

Rr-20cpm

Temp- afebrile

GRBS- 11mg/dl in both hands (168mg/dl after stabilization)

CVS- S1 S2 heard

Rs- BAE+ve

CNS- NFND

P/a- soft non tender

Rx-

IVF NS @75ml/hr IV/STAT

IVF 25-D bolus IV/STAT

GRBS, BP chatting hrly

61 year old farmer (long distance)

This is an 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 patient's clinical problems with collective current best evidence based inputs

61 year old farmer by occupation came with chief complaints of chest tightness

Pt was apparently asymptomatic 10 months back and had developed sudden onset dizziness and chest tightness. Whenever he consumes spicy or heavy foods, he experiences dragging type of pain in the left infra-axillary area of chest 

When he applies pressure on left side of chest(infra axillary area for pain relief), there is relief, belching(+)

Difficulty in passing stools, no blood or mucus in stools

Right thigh- c/o sensation of insect crawling over thigh followed by burning sensation

K/c/o HTN since 2 years, on T.Amlodipine/Atenolol (5/50) po/od

Pt is c c c

Bp-150/80mmHg

Pr-82bpm

Rr-16cpm

Temp-afebrile

Sleep- normal

Appetite normal

Bowel and bladder-regular

No addictions

CVS- S1 S2 heard

Rs- BAE+ve

P/a- soft, non tender

CNS-, NFND

Provisional Diagnosis- Left shoulder pain under evaluation

Department of Orthopaedics referral taken i/v/o Decreased Translucency of L humerus on CXR.

Advised 1. Left Shoulder X-ray AP and axillary view

2. Xray pelvis with both hips- AP view

3.continue short wave diathermy

4. Shoulder girdle exercises

5.T. GABAPIN 10MG PO/HS X 15 DAYS

6. T.MYORIL 4MG PO/BD X 5 DAYS

Diagnosis- LEFT SHOULDER PAIN UNDER EVALUATION WITH LEFT MERALGIA PARASTHETICA WITH H/O HTN

Soap notes 15/122

61 year old male with Left shoulder pain

S- shoulder pain reduced 

O- 

Bp- 180/90 mmhg

Pr- 84 BPM

RR- 16cpm

CVS- S1 S2 heard

RS- BAE +

P/A- SOFT non tender

CNS- NFND

A- L shoulder pain under evaluation with L Meralgia Parasthetica with h/o HTN

P- 

T. PANTOP 40MG PO/OD

T. ULTRACET ½ PO/QID

T . DOLO 650MG PO/TID

T. AMLONG 5MG PO/OD

T. GABAPIN 10MG PO/HS X 15 DAYS

T.MYORIL 4MG PO/BD X 5 DAYS

Shoulder girdle exercises

Continue short wave diathermy

61 year old male with Left infra axillary p pain

S- shoulder pain reduced 

O- 

Bp- 180/90 mmhg

Pr- 84 BPM

RR- 16cpm

CVS- S1 S2 heard

RS- BAE +

P/A- SOFT non tender

CNS- NFND

A- L infra-axillary pain under evaluation (Pain at left Infra axillary area) with Left Maralgia Parasthetica with h/o HTN

P- 

T. PANTOP 40MG PO/OD

T . DOLO 650MG PO/TID

T. AMLONG 5MG PO/OD

T. GABAPIN 10MG PO/HS X 15 DAYS

T.MYORIL 4MG PO/BD X 5 DAYS

Shoulder girdle exercises

Continue short wave diathermy

4th hrly bp monitoring

18/1/22

Review ORTHOPAEDICS REFERRAL

Review PSYCHIATRY REFERRAL

23/F P3L3 with multiple joint swellings

LThis is an 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 patient's clinical problems with collective current best evidence based inputs

26 Year old, P3L3, last child birth 5 years back, a homemaker came to OPD with chief complaints of multiple joint pains, and backache since 3 years

Pt was apparently asymptomatic 3 years back, then developed multiple joint pains, involving small and large joints (B/L DIP, PIP, MCP, wrist, elbow, knee, shoulder, ankle) 

Low backache since 3 years 

A/w ROM, swelling, low grade fever 

Morning stiffness (+) for 10-15 min before resuming activity

20/2/21

RA- positive (February 2021)

Used :

T. METHOTREXATE 7.5MG PO/once weekly

T. SULFAZALAZINE 500MG PO/OD

T. OLFENAC-SR 200MG po/od

T. METHYLPREDNISOLONE (?dosage)

? DICLOFENAC GEL

Used for 6 months with mild reduction in severity of symptoms, discontinued hereafter

Pt is c/c/c

Mild pallor

No icterus, cyanosis, clubbing, lymphedema

CVS- S1, S2 heard

RS- BAE (+)

P/A- soft, non tender

CNS- NFND

Local examination-

MCP, DCP Swelling (+)

No raise of temprature

ROM (+)

No tenderness

Wrist :

ROM (+)

Tenderness (+)

Swelling (+)

L/E (Musculoskeletal system)

Involvement of multiple joints (both large and small)

?Asymmetry (+)

Restriction of movement at Right shoulder

Pain at ankle joint (L>R)

Morning stiffness (+)

No other systemic involvement

Advised: xray B/L wrist with hand, LFT, RFT, Hemogram

Provisional Diagnosis- RHEUMATOID ARTHRITIS WITH MCHC ANEMIA

Department Of Periodontics referral taken i/v/o c/o bleeding gums since 1½ months

Diagnosed as early stage of Gingivitis

Scaling done (one session),advised another session, practise oral hygiene, brushing twice a day and prescribed mouth wash and gum paint for inflammation

Soap notes - 15/1/22 

23/F with multiple joint swellings

S- pain and swelling decreased in B/L UL

 Limping gait (+)

ROM at right shoulder

O- 

O/E-

Pt is c c c 

Temp- afebrile

Bp- 100/70 mmhg

PR- 74bpm

RR- 16cpm

SPO2- 99% 

CVS- S1 S2 heard

Rs- BAE+

CNS NFND

P/a- soft non tender

A- RHEUMATOID ARTHRITIS with MCHC ANEMIA WITH CHRONIC GENERALIZED GINGIVITIS

P- 

T.PREDNISOLONE 10mg po/od

T. FOLIC ACID 5mg PO/OD

T. METHOTREXATE 7.5MG weekly once

T. NAPROXEN 250MG PO/OD

CHLORHEXIDINE mouthwash (twice a day)

STALIN gun paint (twice a day)

17/1/22

Xray right shoulder AP AND AXIAL VIEW

 

23/F with multiple joint swellings

S- pain and swelling decreased in B/L UL

 Limping gait (+)

ROM at right shoulder

O- 

O/E-

Pt is c c c 

Temp- afebrile

Bp- 100/70 mmhg

PR- 74bpm

RR- 16cpm

SPO2- 99% 

CVS- S1 S2 heard

Rs- BAE+

CNS NFND

P/a- soft non tender

A- RHEUMATOID ARTHRITIS with MCHC ANEMIA WITH CHRONIC GENERALIZED GINGIVITIS

P- 

T.PREDNISOLONE 10mg po/od

T. FOLINIC ACID 5mg PO/OD

T. METHOTREXATE 7.5MG weekly once

T. NAPROXEN 250MG PO/OD

T. OROFER XT PO/OD

CHLORHEXIDINE mouthwash (twice a day)

STALIN gun paint (twice a day)

18/1/22

DEPARTMENT OF DERMATOLOGY REFERRAL I/V/O HAIR FALL SINCE 10 MONTHS, AGGREGATED SINCE 2-3 DAYS. 

DX- PEDICULOSIS CAPITIS

ADVISED- 1.PERLICE 1% LOTION (1ST DAY AND 8TH DAY)

2. T. TECZINE 10MG PO/SOS

32 year old male with fever under evaluation

 32 year old male with fever under evaluation

32 year old male patient came to casualty with chief complaints of:

Fever since 3 months

Cough since 3 months

Vomitings since yesterday 

History of present illness :

Patient was apparently asymptomatic 3 months back,then he developed fever which was of high grade associated with headache, chills,continuous,more during night time.

C/O cough since 3 months,dry,no hemoptysis. 

Associated with shortness of breath. 

C/O vomitings since previous day, multiple episodes. Non blood stained, non bilious.

H/O weight loss present. 

H/O loss of appetite present. 

H/O paraplegia 3 months back,admitted, recovered with in 2 months.No bladder and bowel involvement. 

Past history:

H/O koch's 5 years back,used ATT for 4 months and stopped.

H/o paraplegia 3 months back, admitted and recovered a within 2 months, no bowel or bladder involvement. (?GBS)

H/O multiple suicide attempts present. 

Not a k/c/o DM,HTN,asthma,epilepsy,CAD.

Personal history :

Diet-mixed

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular

Alcoholic, stopped 1 and half year back

Smoking 1 pack/ day

General examination:

Vitals on admission:

Temperature-98.8 F

BP-100/80mmhg

PR-88 bpm

RR-17 cpm

Systemic examination:

CNS oriented to t/p/p 

                    Right     left

Power         

Upper limb   4/5     4/5

Lower limb  4/5      4/5

Reflexes 

Biceps          +2       +2

Triceps              -    -

Supinator          -    -

Knee                  -     -

Ankle                 -      -

Plantar flexor    extensor

Thoracic spine tenderness (+)

Referral of Department of Pulmonology i/v/o Cough since 3 months with h/o Pulmonary koch's used ATT for 4 months and stopped. Current cxr shows B/L cavities with sputum for AFB positive. 

Advised- To start ATT acc to FDC guidelines, T. Mucinac 600mg 1 tab in 1 glass water po/Tid, high protein diet, 2 egg a day.

 Dx- fever under evaluation with ?Pulmonary koch's (past h/o ?GBS (AMSAN TYPE)), past h/o peripheral neuropathy with past h/o pulmonary TB (?defaulter)

Treatment:

1)Tab.PCM 650 mg PO/TID

2)Temperature charting 4th hrly

3)Inj.Optineuron 1 amp in 100 ml NS/IV/OD

rx: 

Inj. Optineuron 1amp in 100ml NS IV/od

Inj. Neomol 100ml iv/tid

T. Dolo 650mg po/tid

T. Mucinac 600mg 1tab in q glass water po/tid x3days

Syp. Ambroxyl 15ml po/tid

High protein diet

2 egg whites a day

Temp charting 4th hrly

Bp/PR charting 

DX- Pulmonary koch's rifampicin sensitive