22 YRS OLD FEMALE WITH DURG INDUCED RASH

 HELLO GUYS, 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 evidence based input

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

ADMITTED ON 29/10/21(FRIDAY) 

A 22 YRS OLD FEMALE CAME TO THE CASUALITY WITH

 C/O RASHES OVER BODY WITH ITCHING SENSATION SINCE 4 DAYS

FEVER SINCE 8 DAYS BACK, HIGH GRADE A/W CHILLS DECREASED ON MEDICATION

A/W GENERALISED BODY PAINS+

H/O HERBAL MEDICATION ON THE (TUESDAY)

F/B RASHES OVER THE LIMBS /BODY NEXT DAY

NO H/O COLD, COUGH

H/O GENERALISED EDEMA ALL OVER THE BODY SINCE 3DAYS 

 NO H/O DECREASED URINE OUTPUT AND ABDOMINAL DISTENSION

PATIENT SAYS THAT SHE HAVE TAKEN HERBAL MEDICATIONS FOR JAUNDICE 

(WENT TO HERBAL PRACTITIONER WITH C/O FEVER ON AND OFF FOR 10 DAYS AND 2 DAYS VOMITING EPISODE)

PAST HISTORY:

N/K/C/O DM,TB,ASTHMA,CVA,

CAD, EPILEPSY

PERSONAL HISTORY:

APPETITE: NORMAL

DIET: VEGETARIAN

NO ANY ADDICTION

REGULAR BOWEL AND BLADDER MOVEMENTS

ADEQUATE SLEEP

GENERAL EXAMINATION:

PT IS C,C,C

PALLOR - PRESENT

GENERALISED EDEMA -PRESENT

RASHES PRESENT ALL OVER THE BODY

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, 

VITALS:

TEMP- 101 F

PULSE- 120 bpm

RR- 20 cpm

BP- 90/70 mmHg

SPO2- 99@ROOM AIR

GRBS- 86 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2 ,NO MURMURS

RS: BAE+,NVBS+

CNS: NFD

P/A: SOFT, NON-TENDER

INVESTIGATIONS:(29/10/2021)

1)HEMOGRAM:

2)CUE:

3)BLOOD GROUP:

4)PT,INR:

5)APTT:

6)LFT:

7)RFT:

8)RBS:

9)RAPID DENGUE TEST:

10)ECG:

11)USG ABDOMEN:

-GALLBLADDER EDEMA,

-MILD SPLENOMEGALY

-MINIMAL ASCITES

DVL REFERRAL DONE:

OUTSIDE REPORTS:

DIAGNOSIS: DRUG INDUCED RASH

TREATMENT:

1.T.UDILIV 300mg PO/BD 

2.SYRUP. LACTULOSE 15ml PO/OD IN NIGHT

3.T.ATARAX 25mg PO/OD IN NIGHT

4.T.PCM 500mg PO/SOS

INVESTIGATIONS ON DAY2(30/10/2021):

HEMOGRAM

RETICULOCYTE COUNT:

LFT:

LDH:

CRP -POSITIVE

DAY-3:

Soap notes

Icu 6th bed:

S: 

1 Fever spike at 4:00am

Itching decreased

Rashes present 

O:

PR: 82bpm

Bp: 120/80mmhg

Temp: 99F

RR:18cpm

Cvs:s1,s2heard

Rs:BAE+

CNS:NFD

Generalised edema present.

Rashes present all over the body

A:

Hepatitis secondary to Drug induced(herbal medication)

P:

1)Tab.UDILIV 300mg PO/BD

2)SYP.Lactulose 1ml/po/H/s

3)Tab.ATARAX 25mg PO/OD/Hs

4)Tab.RIBOFLAVIN 10MG PO/BD

5)Tab.PCM 500mg PO/SOS

6)Tab.Zincovit po/od

DAY-4 (1/11/021)

Soap notes

Icu 6th bed:

S: 

Fever spikes present the while night 

Itching has decreased

Rashes present 

O:

PR: 82bpm

Bp: 120/80mmhg

Temp: 98.1F at 7am

RR:18cpm

Cvs: S1,S2 heard

Rs: BAE+

CNS:NFD

Generalised edema present.

Rashes present all over the body

A:

Hepatitis secondary to Drug induced(herbal medication)

P:

1)SYP.Lactulose 15ml/po/H/s

2)Tab.ATARAX 25mg PO/OD/Hs

3)Tab.RIBOFLAVIN 10MG PO/BD

4) Tab.PCM 500mg PO/SOS

5) Tab.Zincovit po/od

MEDICINE CASE DISCUSSION

HELLO GUYS, 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 evidence based input

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

UNIT 5 ADMISSION 

 32 year old male came to the casualty with clo Pain abdomen in epigastim ,left hypochondrium Since 1 day.

C/o vomiting since 1day (non-billious,non projectile) 2episodes ,containing food-particles

Passing flatus, constipation since 1day morning

Loss of appetite+

No c/o fever

HISTORY OF PAST ILLNESS :

not a K/c/o DM HITN, epilepsy,asthma, CVA,CAD .

PERSONAL HISTORY:

Loss of appetite+,takes mixed diet ,bowel and bladder movements were regular .

H/o alcohol consumption(beer) since 5yrs(2times a day) stopped 1 month back. 

ON EXAMINATION:

Patient  is conscious ,coherent ,co-operative 

Temp-98f

PR-90BPM

RR-20CPM

BP-100/70mmhg

GRBS-266MG/DL

Spo2-98@RA

CVS-S1S2+

RS-BAE+,NVBS

P/A-SOFT,NON TENDER,B/S+

CNS-NAD

PROVISIONAL DIAGNOSIS:

ACUTE PANCTREATITIS SECONDARY TO ALCOHOL

INVESTIGATIONS:

TREATMENT:

1)IVF- NS,RL-150ML/HR

2)INJ.PAN.40MG/IV/BD

3)INJ. THIAMINE 200MG IN 100ML NS /IV/BD

4)INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD

5)INJ.TRAMADOL 1AMP IN 100 ML NS/IV / BD

6)INJ .ZOFER 4MG /IV/BD

7)strict I/O monitoring 

8)BP,PR,SPO2 Monitoring 4th helt

9)GRBS monitoring 6hrly

 SOAP NOTES DAY-2

S: No fresh complaints

Pain abdomen decreased

O:

PR: 82bpm

Bp: 130/80mmhg

Temp: 99F

RR:18cpm

Cvs:s1,s2heard

Rs:BAE+

CNS:NFD 

GRBS :157 mg/dl

A:

Acute pancreatitis secondary to alcohol with denovo diabetes

P:

1)IVF :NS and RL 100 ml /hr

2)INJ pantop 40 mg IV BD

3)INJ.THIAMINE 200MG IN 100ML NS IV/OD (OVER 30MIN)

4)INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

5)INJ.ZOFER 4MG IV/BD

6)INJ.HAI S/C,acc to GRBS

7)BP,TEMP MONITORING

Medicine case discussion

  General medicine case 

HELLO GUYS, 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 evidence based input

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints:-

A 38 year old female came to casuality with chief complaints of fever and vomitings since 3 days.

History of present illness:-

Patient was apparently asymptomatic  3 days back then she developed fever which is of low grade and associated with chills and rigors and are relived on medication.

Vomting since 3days  of 2episodes daily which was non-bilious and no projectile , containing food particles. History of cold and cough (non productive) were present since 3 days.

No complaint of ‘pedal oedema ,decreased urine output and abdominal distension’.

No complaint of chest pain , palpitations and sob.

History of past illness:-

N/k/c/o HTN, DM, TB, Asthma, CVA, CAD, Epilepsy.

Personal history:-

Marital status:- married

Appetite:- lost

Diet:- mixed

Bowels:- regular

Micturition:- normal

No known allergies.

Family history:- not significant.

Physical examination:-

General examination:-

Patient is c/c/c with moderate build and moderate nourishment 

Pallor:- no

Icterus:- no

Cyanosis:-no

Lymphadenopathy:- no

Malnutrition:-no

Dehydration:-no

Clubbing:- no

Vitals:-

Temperature:- Afebrile

Pulse rate:- 90 bpm

Respiration:-22 cpm

Bp:- 70/50 mmhg

Spo2:- 98%

GRBS:-140 mg/dl

Systemic examination:-

CVS :-s1 and s2 heard,No murmurs.

Rs:-BAE+,NVBS

P/A:-soft and non-tender.

CNS:-No focal deformities.

INVESTIGATIONS:-

Hemogram:-

LFT:-

RFT:-

Serology:- negative

CXR:-

ECG:-

Fever chart:-

Diagnosis:- viral pyrexia with acute gastritis

Treatment given:-

INJ ZOFER 4 mg IV / TID   1-1-1

IVF NS

        RL   @ 100 ml /hr

INJ PAN 40mg IV OD   1-X-X

INJ OPTINEURON 1 amp IN 100 ml NS IV /OD  (OVER 30 mins)    1-X-X

SYP ASCORIL D  10 ml / TID 

10ml  -  10ml  -10ml

ORS

Day 2 SOAP NOTES :-

S-

No fever,cold, vomitings

c/o cough

No fresh complaints

O-

Bp-110/80mmhg

Pr- 86bpm

Cvs:s1s2heard

Rs: BAE+

P/A: soft

A-

Viral pyrexia with acute gastritis

Hb:11gm/dl

Tc:3600

Platelets:1.51

Smear: normocytic normochromic

P-

Inj.Zofer 4mg iv/sos

Inj.PAN 40mg/iv/od

Ivf NS,RL @50ml/hr

Inj.OPTINEURON 1amp in100ml ns/iv/od

Syp.ASCORIL-D 10ml/tid

ORS

Patient was relieved symptomatically and her vomtings was subsided.She had a small daughter , and wanted to take care of her.so, she wanted to go home today(10/10/21). She was discharged at request.

 Diagnosis- viral pyrexia (dengue NS1 positive)

UNIT 5 ADMISSION:

Chief complaints

A 14year old male resident of chanduru came in to casualty with chief complaints of 

fever since 4 days. C/o cough since 4days

Presenting illness

Patient was apparently asymptomatic 4 days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and body pains.

C/O cough since 4 days which is associated with sputum . 

Patient has  h/o  1episode of vomiting 2days back which is non bilious,non projectile.

No h/o pedal oedema,decreased urine output,sob,palpitations.

No h/o chest pain,abdominal pain

PAST HISTORY:

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

PERSONAL HISTORY:

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

FAMILY HISTORY

No significant family history or allergic history. 

GENERAL EXAMNATION:

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 100/80 MMHG, 

PR: 90bpm 

Temp: 98.2°F, 

RR: 22 CPM, 

SPO2: 98% 

RS: BAE+,NVBS

Cvs: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities. 

INVESTIGATIONS:

1) HEMOGRAM : 

Hb: 12.6

TLC: 4,200

PCV: 37.6

PLT: 3.41

2) LFT:

TB: 0.76

DB: 0.25

SGOT: 51

SGPT: 21

AP: 519

TP: 6.3

A: 2.2

A/G: 0.55

3)CUE

Alb:trace

Sug:nill

Ec:2-3

Pc:2-3

RBC:bill

4)BLOOD UREA:34

 5)SERUM ELECTROLYTES:

Na+:136

K+:4.1

Cl-:102

Absolute neutrophil count"-

Peripheral smear:-

Rapid dengue test:-

Fever chart

SOAP NOTES DAY 1:-

AMC case

S- complains of fever,cold,cough 

O-bp-130/100

Pr-89

Rr-17

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 75 ml/hr

Tab.augmentin 625 mg po/bd

Tab.dolo 650 mg po/tid

Inj.pan 40 mg/po/od

Inj.optineuron 1 amp in 100 ml NS IV od

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Inj.neomol 1 g/IV/sos only if temperature greater than 101°F

Watch for bleeding manifestations and postural drop.

Soap notes day 2:-

AMC case

14/M

S- no fresh complaints

O-bp-90/60

Pr-88

Rr-17

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 25 ml/hr

Inj.augmentin 1.2g iv/OD

Tab.dolo 650 mg po/tid

Inj.pan 40 mg/po/od

Inj.optineuron 1 amp in 100 ml NS IV od

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Inj.neomol 1 g/IV/sos only if temperature greater than 101°F

Watch for bleeding manifestations and postural drop.

Soap notes day 3:-

AMC case

14/M

S- 1fever spike ,no fresh complaints

O-bp-100/70mmhg

Pr-80

Rr-20

Cvs-s1,s2 heard

Resp- bae +

Per abdomen-soft,non tender,bowel sounds present.

A- viral pyrexia (Dengue NS1 positive)

P-

IV FLUIDS-NS,RL @ 100ml/hr

Inj.augmentin 1.2g iv/BD

Inj PCM 1gm IV/sos

Inj.Zofer 4 mg/IV/sos

Tab. Doxycycline 100mg/po/bd

Syr.grillinctus bm 100 ml/po/tid

Plenty of oral fluids

Watch for bleeding manifestations and postural drop.

Strict temp monitoring 4th hrly

PROVISIONAL DIAGNOSIS:DENGUE FEVER NS1positive