Evidence based date wise workflow logs collated by the intern with clickable and verifiable link
2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links
As of 19/9/23 :-
CASE 1:-
PaJR Group
https://chat.whatsapp.com/Jc43jR1klLF7ovLA3oagvU
Blog :-
https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html
[05/09/23, 8:54:43 AM] ~ Keerthi Madireddi: @919381040824 update soap notes and also draw a graph showing the potassium values and intervention done.
[05/09/23, 8:55:52 AM] Keerthana: Ok mam
[05/09/23, 9:02:57 AM] ~ Keerthi Madireddi: @919381040824 please make me and hod sir as admin
[05/09/23, 9:04:03 AM] ~ Keerthi Madireddi: ☝🏻
[05/09/23, 9:46:51 AM] Rakesh Biswas Sir Hod Medicine: Mention duration in the title
[05/09/23, 10:40:57 AM] Keerthana: Date-5/9/23
Ward-ICU Bed 5
Unit 6
Date of admission 2/9/23
S -
C/o weakness in both upper and lower limb,
C/o slurring of speech since 4 days
O -
On examination
Patient is conscious coherent and cooperative.
No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp: 98.6 F
PR: 72 bpm
BP:120 /80 mm hg
RR: 25 cpm
CVS: S1 ,S2 heard
RS:B/L AE present , NVBS +. No added sounds
P/A:Soft, non tender, no organomegaly.
No rigidity,Guarding.
CNS: Rt Lt
Tone U/L Hyper Hyper
L/L Normal Normal
Power- U/L 4-/5 4-/5
L/L 4-/5 4/5
Reflexes- B 3+ 3+
T 3+ 3+
S. 3+. 3+
Knee 3+ 3+
Ankle. 1+. 1+
Plantar Mute Mute
A:? Hypokalemic periodic paralysis. denovo htn
P:
1) IV NS @50 ml/hr
2) Syp. Potklor 15 ml in 1 glass of water PO/TID
3) T. ECOSPRIN -AV 75/10 Po/ Hs
4) Strict I/o charting
5)Monitor vitals every 2nd hrly
6)T.Telma 40 mg Po /OD
7)Inj. Ceftrioxone 1gm IV/ Bd
[05/09/23, 10:42:50 AM] Rakesh Biswas Sir Hod Medicine: Why ceftriaxone? @919908159666
[05/09/23, 10:44:15 AM] Rakesh Biswas Sir Hod Medicine: What about the leg ulcer? Why is that not mentioned? Cause and duration of the ulcer?
[05/09/23, 10:45:41 AM] Keerthana: Will mention it sir
[05/09/23, 10:53:17 AM] Keerthana: Sir the ulcer of the leg was his past illness( a year ago) for which he was treated with regular debridement and dressing and the ulcer is healed now. There nothing to be done for the ulcer as it healed.only thing can be done is graft placement for the purpose of cosmetic purpose.
As of now major issue is his hypokalemia causing weakness of limbs
[05/09/23, 11:01:22 AM] Narsimha Sir Gm Pgy2: What about Slurring of Speech during admission ??
[05/09/23, 11:02:17 AM] Narsimha Sir Gm Pgy2: What was the Reason for his Chronic Ulcer ? Is it Diabetes ?? What about his FBS ; PPBS & HbA1c
[05/09/23, 11:03:19 AM] Keerthana: Sir , ceftriaxone is started because the counts of the patient is raised I.e., 16200 and as it is 3 rd generation cephalosporin it shows it’s activity on both gram positive and negative bacteria so it was started!
[05/09/23, 11:08:24 AM] Narsimha Sir Gm Pgy2: Can Hypokalemia Present with Slurring of Speech ??
[05/09/23, 11:08:50 AM] Narsimha Sir Gm Pgy2: Or it was due to his C2H5OH ??
[05/09/23, 11:23:23 AM] Rakesh Biswas Sir Hod Medicine: What bacteria would be raising the counts?
Is it a good idea to treat the counts and not the patient?
[05/09/23, 11:26:39 AM] Keerthana: Intially the Counts were raised sir ....But Clinically he was good ...But Since Yesterday He was having Fever Spikes & We didn't Localise the cause yet So We thought of Starting him on Emperical antibiotics. But did not start yet
Case 2- Pajr - https://chat.whatsapp.com/KlmU0d1YfEdCmf4DpUINKb
[04/09/23, 11:10:18 AM] Keerthana: S - C/o high grade fever since 5days
associated with chills and rigors.
no h/o vomitings, pain abdomen,
O - viral pyrexia (Dengue NS1 positive)
A: On examination
Patient is conscious coherent and cooperative.
No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp: 98.8 F
PR: 81 bpm
BP:110 /70 mm hg
RR: 17 cpm
CVS: S1 ,S2 heard
RS:B/L AE present , NVBS +. No added sounds
P/A:Soft, non tender, no organomegaly.
No rigidity,Guarding.
CNS: NAD
P:
1) IV FLUIDS NS @100ml/hr
2) Inj. Neomol 1gm / SOS IF TEMP 101 F
3) Tab. Dolo 650 mg PO/ SOS
4)MONITOR VITALS
[05/09/23, 1:45:07 PM] Keerthana : Dengue is called saddleback fever because the fever remits at least for one day, and the next fever spike starts, which lasts at least for one more day.
Case 3 -
Pajr
https://chat.whatsapp.com/H3MGX0P0llGFpUBMl3ynhq
Blog - https://kattaphanikeerthanarollno72.blogspot.com/2023/09/52-year-old-female-with-chief.html
Chief complaints-
C/o Headache since I month
Co Pain over the DIP joint
elbow joint and shoulder joint
since lmonth
2. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic
1 month back, then developed headache
associated with Neckpain, radiating to B/L upper limbs.
Aggrevated with bending forward, relleved with medication clo Pain over the DIP, elbow joint and shoulder joint
-since Imonth, B/L symmetrical in distibution, with morning stiffness lasting for around 5-10 mins,
- No C/o sOB /palpitations (chest pain )
orthopnea
- No c/o Fever decreased urinary output| PND
burning micturition.
3. HISTORY OF PAST ILLNESS
Not a klo HTN, DM2 , thyroid disorders
Bronchial Asthma, CVA, CAD ,TB
Allergic history:-
No history of any kind of allergies to food/drugs
Family history:-
No significant family history
GENERAL EXAMINATION:-
THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY
TEMPERATURE:- 98.8 F
PR:81bpm
BP:120/70 mmHg
RR:17cpm
o/E: of B/L hand:
B/L symmetrical DIP Joints
Pain present over it.
No tenderness
Synovial thickening-
No external deformity
SYSTEMATIC EXAMINATIONS:-
CVS:S1 S2+,NO MURMURS
CNS: NAD
RS:BAE+ ; NVBS
P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY
PROVISIONAL DIAGNOSIS:-
? Cervical spondylosis ? Rheumatoid Arthritis
Investigations
Hemogram 12/9/23
Hb- 10.4
TLC - 7200
Plt count - 2.64
Pcv - 32.1
Mcv - 83.8
Mch - 27.2
Mchc- 32.4
UREA 28
CREATININE 0.9
Sodium - 143
Potassium- 3.7
Chloride -103
CUE - albumin- nil sugar- nil bile salts- nil
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