This is an online E - log book to discuss our patients 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. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.
CHIEF COMPLAINTS:
FEVER SINCE 1 MONTH, REDUCED APPETITE SINCE 1 MONTH, WEIGHT LOSS SINCE 1 MONTH, URINARY URGE INCONTINENCE SINCE 1 MONTH
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN HE DEVELOPED FEVER OF REMITTENT TYPE WITH NO AGGRAVATING FACTORS NOT ASSOCIATED WITH CHILLS C/O GENERALIZED WEAKNESS C/O URINARY URGE INCONTINENCE WITH NO H/O POLYURIA AND PRURITIS C/O INVOLUNTARY DEFECATION DURING URINATION SINCE 15 DAYS
NO H/O CHEST PAIN, CHEST TIGHTNESS, PALPITATION, ABDOMINAL PAIN, BLEEDING MANIFESTATION
HISTORY OF PAST ILLNESSES:
K/C/O TB AND UNDERWENT TREATMENT
K/C/O DM SINCE 7 YEARS AND ON MIXTARD
K/C/O SEIZURES EPISODES 7 YEARS BACK UNDERWENT TREATMENT
N/K/C/O ASTHMA, HTN, CAD
PERSONAL HISTORY:
Married
Normal appetite
irregular bowel movement (involuntary during micturition)
abnormal micturition (urge incontinence)
Adequate sleep
No addictions
FAMILY HISTORY:
N/K/C/O DM, HTN, Epilepsy, TB, asthma;
GENERAL EXAMINATION :
- PT IS CONSCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .
- NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA.
- TEMP - 97.6 F
- PR- 90 BPM
- RR- 20 CPM
- BP- 110/60 MM HG
- SPO2- 98% AT RA
- GRBS- 247MG/DL
SYSTEMIC EXAMINATION -
CVS- S1,S2 HEARD,NO MURMURS
RESPIRATORY SYSTEM-TRACHEA CENTRAL,VESICULAR SOUNDS HEARD
ABDOMEN-NO TENDERNESS,DISTENTION,ORGANOMEGALY
CNS-NO FOCAL DEFICITS
ON 1/05/2024 PULMONOLOGY REFERRAL WAS TAKEN I/V/O PULMONARY TB
ON 1/05/2024 OPHTHALMOLOGY REFERRAL WAS TAKEN I/V/O DIABETIC RETINOPATHY CHANGES AND CHOROID TB
IMPRESSION NORMAL FUNDUS
NEUROSURGERY REFFERAL TAKEN ON 7/5/24 I/V/O PREVERTEBRAL ABSCESS
ADVICE: CONTINUE ATT AND REVIEW AFTER 4 WEEKS
NEPHROLOGY REFFERAL TAKEN ON 1/5/24 I/V/O ORAL CONTRAST AND IV CONTRAST ON CECT
ADVICE: TAB. N-ACETYLCYSTEINE 1200MG PO/BD
IV FLUIDS 1ML/KG/HR FOR 12 HOURS BEFORE CECT FOLLOWED BY IV FLUID 1ML/KG/HR AFTER CECT
PULMONOLOGY REFERRAL DONE ON 1/5/24 I/V/O PULMONARY TUBERCULOSIS
ADVICE: CST
HRCT CHEST
REVIEW WITH REPORT
OPHTHALMOLOGY REFERRAL DONE ON 1/5/24 I/V/O FUNDOSCOPY, RETINOPATHY AND CHOROID TB
IMPRESSION: NORMAL FUNDUS STUDY
UROLOGY REFERRAL DONE ON 1/5/24
ADVICE: CUE, USG KUB,CBP, URINE C/S
REVIEW WITH REPORTS
ORTHOPEDIC REFERRAL DONE ON 3/5/24 I/V/O FEMUR IMPANT, KNEE PAINS AND PREVERTEBRAL COLLECTION FROM C4 TO L1 LEVEL 85 X 30 X 36 AND EROSION OF C6 VERTEBRAL BODY.
ENT REFERRAL TAKEN ON 4/5/24 I/V/O VOCAL POLYPS AND ? NASAL POLYP
ADVICE: CONTROL ACTIVE STAGE OF TB AND REVIEW TO ENT OPD FOR ENDOSCOPY
CONTINUE MEDICATIONS ADVISED BY PRIMARY PHYSICIAN
PROVISIONAL DIAGNOSIS:
PYREXIA UNDER EVALUATION SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA
DISSEMINATED TB PULMONARY TB POTTS SPINE RENAL TB
CHRONIC KIDNEY DISEASE STAGE 3 B
CHRONIC PANCREATITIS
ANEMIA OF CHRONIC DISEASE
Investigations:
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MRI-
CT-
HRCT DONE ON 2/05/2024
IMPRESSION CHRONIC COLLAPSE OF LEFT UPPER LOBE WITH CAVITIES AND BRONCHIECTASIS WITHIN
PATCHY CONSOLIDATION AND MULTIPLE SMALL NODULES IN B/L LUNGS
MULTIPLE VARIABLE SIZED THIN WALLED CAVITIES IN B/L UPPER LOBES AND RIGHT MIDDLE LOBE
RIGHT KIDNEY SHOWS A 54X34 MM SPACE OCCUPYING LESION
PREVERTEBRAL COLLECTION FROM C4-D1 LEVEL 85X30X36 MM
EROSIONS OF C6 VERTEBRAL BODY
ECG-NORMAL SINUS RHYTHM
USG ABDOMEN WAS DONE ON 29/4/24
IMPRESSION: CHRONIC PANCREATITIS
LEFT KIDNEY SHOWS GRADE II RPD CHANGES WITH SIMPLE RENAL CYST
RIGHT KIDNEY SHOWS GRADE I RPD CHANGES
TREATMENT:
ATT STARTED ON 5/5/24
30/4/24:
IV FLUIDS- NS AT 75ML/HOUR
INJ. AUGMENTIN 1.2GM IV/BD 8AM---X--8PM
INK PAN 40MG IV/OD 7AM--X--X
INJ. NEOMOL IGM IV/SOS
TAB. AZITHROMYCIN 500MG PO/OD AT 2PM
INJ. OPTINEURON 1 AMP IN 100ML NS
TAB. DOLO 650MG TID 8AM--2PM--8PM
INJ. HAI S/C TID ACCORDING TO GRBS
NEBULISATION WITH BUDECORT 12TH HOURLY
IPRAVENT 6TH HOURLY
1/5/24:
IV FLUIDS NS AT 75ML/HOUR
INJ. AUGMENTIN 1.2GM IV/BD 8AM---X--8PM
INK PAN 40MG IV/OD 7AM--X--X
INJ. NEOMOL IGM IV/SOS
TAB. AZITHROMYCIN 500MG PO/OD AT 2PM
INJ. OPTINEURON 1 AMP IN 100ML NS
TAB. DOLO 650MG TID 8AM--2PM--8PM
INJ. HAI S/C TID ACCORDING TO GRBS
NEBULISATION WITH BUDECORT 12TH HOURLY
IPRAVENT 6TH HOURLY
2/5/24:
IV FLUIDS NS AT 75ML/HOUR
INJ. AUGMENTIN 1.2GM IV/BD 8AM---X--8PM
INK PAN 40MG IV/OD 7AM--X--X
INJ. NEOMOL IGM IV/SOS
TAB. AZITHROMYCIN 500MG PO/OD AT 2PM
INJ. OPTINEURON 1 AMP IN 100ML NS
TAB. DOLO 650MG TID 8AM--2PM--8PM
INJ. HAI S/C TID ACCORDING TO GRBS
NEBULISATION WITH BUDECORT 12TH HOURLY
IPRAVENT 6TH HOURLY
3/5/24:
IV FLUIDS NS AT 75ML/HOUR
INJ. PIPTAZ 4.5 GM IV/STAT FOLLOWED BY INJ. PIPTAZ 2.25G IV/TID
INJ. AUGMENTIN 1.2GM IV/BD 8AM---X--8PM
INK PAN 40MG IV/OD 7AM--X--X
INJ. NEOMOL IGM IV/SOS
TAB. AZITHROMYCIN 500MG PO/OD AT 2PM
INJ. OPTINEURON 1 AMP IN 100ML NS
TAB. DOLO 650MG TID 8AM--2PM--8PM
INJ. HAI S/C TID ACCORDING TO GRBS
NEBULISATION WITH BUDECORT 12TH HOURLY
IPRAVENT 6TH HOURLY
4/5/24:
IV FLUIDS NS AT 75ML/HOUR
INJ. PIPTAZ 4.5 GM IV/STAT FOLLOWED BY INJ. PIPTAZ 2.25GM IV/TID
INJ. AUGMENTIN 1.2GM IV/BD 8AM---X--8PM
INJ. PAN 40MG IV/OD 7AM--X--X
INJ. NEOMOL IGM IV/SOS
TAB. AZITHROMYCIN 500MG PO/OD AT 2PM
INJ. OPTINEURON 1 AMP IN 100ML NS
TAB. DOLO 650MG TID 8AM--2PM--8PM
INJ. HAI S/C TID ACCORDING TO GRBS
NEBULISATION WITH BUDECORT 12TH HOURLY
IPRAVENT 6TH HOURLY