THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDNCE BASED INPUTS.
25 YR OLD FEMALE WORKS IN PETROL BUNK, RESIDENT OF DHAMARACHARLA CAME TO OPD WITHC/O DIFFICULTY IN WALKING. SINCE 4 DAYS. PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 10 DAYS AGO THEN HAD C/O FEVER WENT TO LOCAL HOSIPTAL AND TREATED, AFTER TREATMENT PATIENT HAD C/O LOOSE STOOLS 4-5 EPISODES PER DAY MUCOID, GREENISH COLOUR, NON-BLOOD STAINED, NON-FOUL SMELLING, LARGE QUANTITY AGGRAVTED ON HAVING FOOD, WENT TO LOCAL RMP AND GOT TREATED SYMPTOMS SUBSIDED. SINCE 4 DAYS PATIENT HAD C/O BACK PAIN SUDDEN ONSET F/B NECK PAIN AT CERVICAL REGION, NON-RADIATING F/B RIGHT KNEE PAIN AND SWELLING. RIGHT INDEX FINGER PAIN A/W SHOCK LIKE SENSATION.
N/K/C/O DM, HTN, TB, CVA, CAD, ASTHMA, EPILEPSY, THYROID DISORDERS.
GENERAL PHYSICAL EXAMINATION
PATIENT IS CONSCIOUS, COOHERENT, COOPERATIVE
TEMP-98.4F
PR-95BPM BP-110/70MMHG
SPO2 97%RA
GRBS -93
CVS-S1S2 +
RS BAE +, NVBS
P/A SOFT, NON-TENDER
CNS E4V5M6
PUPILS - B/L PUPILS REACTIVE
TONE
LT UL- NORMAL LL NORMAL
RT ULNORMAL LT- NORMAL
POWER
LT UL-4/5 LL4/5
RT UL 4/5 LL 3/5
REFLEXES
BICEPS - RT +2, LT +2
TRICEPS RT - LEFT -
SUPINATOR RT+ LT +
KNEE RT +2 LT +2
ANKLE RT + LT +
PLANTARFLEXION RT FLEXION LT FLEXION CRANIAL NERVES -
1-NORMAL
2-NORMAL
3-NORMAL
4-NORMAL
5-NORMAL
6-NORMAL
7-NORMAL
8 -NORMAL
9-NORMAL
10-NORMAL
11-NORMAL
12-NORMAL
COURSE IN THE HOSPITAL
24 YEAR FEMALE CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS, NECESSARY INVESTIGATIONS DONE AND DIAGNOSED WITH REACTIVE ARTHRITIS SECONDARY TO ENTERIC FEVER. ON DAY 2 OF ADMISSION PAINS SUBSIDED. ON DAY 3 OF ADMISSION PATIENT COMPLAINED OF RIGHT KNEE PAIN, AND 2 EPISODES OF LOOSE STOOLS WITH UNDIGESTED FOOD PARTICLES. ON DAY 4 OF ADMISSION PATIENT HAD BILATERAL KNEE PAINS, LOOSE STOOLS SUBSIDED. ON DAY 5 AND 6 PATIENT IS SYMPTOMATICALLY BETTER WITHOUT ANY FEVER SPIKES. PATIENT WAS CONSERVATIVELY MANAGED WITH IV ANTIBIOTICS AND NSAIDS. PATIENT IS HEMODYNAMICALLY BETTER AND PLANNED FOR DISCHARGE.
Investigation
Blood Urea 11 mg/dl 42-12 mg/dl Serum Creatinine 0.8 mg/dl 1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l)
27-03-2024 12:55:PM SODIUM 111 mmol/L 145-136 mmol/L POTASSIUM 3.3 mmol/L 5.1-3.5 mmol/L CHLORIDE 84 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 27-03-2024 12:55:PM Total Bilurubin 0.99 mg/dl 1-0 mg/dl
Direct Bilurubin 0.28 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 17 IU/L 31-0 IU/L
SGPT(ALT) 15 IU/L 34-0 IU/L
ALKALINE PHOSPHATASE 84 IU/L 98-42 IU/L
TOTAL PROTEINS 4.2 gm/dl 8.3-6.4 gm/dl
ALBUMIN 2.14 gm/dl 5.2-3.5 gm/dl
A/G RATIO 1.04
COMPLETE URINE EXAMINATION (CUE) 27-03-2024 12:55:PM COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP. GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent OTHERS Nil
HIV - NEGATIVE
HBsAg-RAPID 27-03-2024 12:55:PM Negative
Anti HCV Antibodies - RAPID 27-03-2024 12:55:PM Non-Reactive
BLOOD UREA 27-03-2024 10:56:PM 16 mg/dl 42-12 mg/dl
SERUM CREATININE 27-03-2024 10:56:PM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 27-03-2024 10:56:PM SODIUM 137 mmol/L 145-136 mmol/L
POTASSIUM 4.0 mmol/L 5.1-3.5 mmol/L
CHLORIDE 103 mmol/L 98-107 mmol/L
STOOL FOR OCCULT BLOOD 27-03-2024 10:56:PM Negative (-ve) CRP - + POSITIVE
ESR - 40MM
RBS - 78MG/DL
HEMOGRAM-27/3/24
HB-7.6GM/DL
TLC -9000 CELLS/CUMM
PLATELET COUNT - 2.8 LAKH/CUMM NORMOCYTIC NORMOCHROMIC ANEMIA. HEMOGRAM ON 28/3/24:
HB-9.4GM/DL
TLC -8,200CELLS/CUMM
PLATELET COUNT - 3.5 LAKH/CUMM NORMOCYTIC NORMOCHROMIC ANEMIA. HEMOGRAM ON 29/3/24:
HB-9.9GM/DL
TLC -12,400CELLS/CUMM
PLATELET COUNT - 4.5 LAKH/CUMM
NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS PERIPHERAL SMEAR:
RBC: Normocytic normochromic few microcytes
WBC: With in normal limits
PLATELET: Adequate
IMP: Normocytic normochromic anemia
RECTIC COUNT:1.0%
SERUM LDH:130IU/L
SR.IRON:
USG ABDOMEN AND PELVIS -
NO SONOLOGICAL ABNORMALITY DETECTED Treatment Given (Enter only Generic Name) INJ.MONOCEF 1GM IV/BD X 4 DAYS INJ.NEOMOL 1G IV/SOS
TAB.NAPROXEN 250MG PO/TID 1-1-1 TAB.ULTRACET 1/2 TAB PO/QID 1/2-1/2-1/2-1/2 TAB.PAN 40 MG PO / OD 1-0-0 TAB.REJUNEX-CD3 PO/OD 0-1-0 TAB.SPOROLAC -DS PO/TID 1-1-1
DOROLAC - Z SACHET PO/BD 1-0-1
Advice at Discharge
TAB TAXIM 200MG PO/TID 1-1-1 X 2 DAYS
TAB INDOCAP SR 75MG PO/OD 1-0-0 X 2 DAYS TAB.NAPROXEN 250MG PO/TID 1-1-1 X 5DAYS TAB.PAN D PO / OD 1-0-0 X 5DAYS TAB.REJUNEX-C03 PO/OD 0-1-0 X 15DAYS
TAB SPORLAC DS 1TAB PO/TID 1-1-1 X 2 DAYS DOROLAC - 2 SACHET PO/BD 1-0-1 X 2 DAYS
[13-07-2025 17.42] PPM 1: Patient update?
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