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


PHOTO-2023-09-05-10-41-22.jpeg

[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 


Blog - https://kattaphanikeerthanarollno72.blogspot.com/2023/09/38-year-old-male-with-fever-since-4-days.html 


PHOTO-2023-09-04-11-03-16.jpeg

[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.


PHOTO-2023-09-05-13-45-13.jpeg




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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