Evidence based date wise workflow logs.

 EVIDENCE BASED DATE WISE WORKFLOW LOGS 


CASE 1

9/11/2023

PAJR link

https://chat.whatsapp.com/D4GwL7frFWfAEuJbMXbNW8

Case report link 

https://nvprathyusha100.blogspot.com/2023/11/31-yr-old-female-with-fever-since-5.html?m=1

A 31 year female came with chief complaints of fever since 5 months.

Fever is high grade associated with chills and rigor , intermittent in nature, No diurnal variation

It is associated with vomiting , food as content , no bilious , non projectile , no blood stained  

H/o loss of appetite & weight loss 

H/o burning sensation over the tongue and buccal mucosa since 3-4 months, insidious in onset, gradually progressive, aggravated when patient consumes spicy food and no relieving factors

No h/o cough, cold

No h/o chest pain , sob, orthopnea, pnd

No h/o loose stools, constipation

No h/o burning micturition, increased/decreased urine output.

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

Vitals : 

PR  : 76 bpm

BP : 110/70 mmHg 

RR : 20 cpm

Temperature : 101F

Spo2 : 98 %

GRBS : 92mg /dl


Investigations:

Hb- 8.3 mg/dl

PCV- 25.4 

TLC -4900 

RBC -3.6

PLT -3.99

RBS- 103

S CREAT- 0.6mg/dl

S. Na -131mEq/l

S. K -3.3mEq/l

S . Cl -98 mEq/l

CRP -2.4 mg/dlS

.cal -1.04

TB -1.0

DB- 0.18

SGPT- 24

SGOT -65

ALP -116

TP -7.1

ALB -3.7

A/G - 0.83

[11/11, 15:50] Rakesh Biswas Gm Hod Sir Kims: Fever Chart since admission?

[11/11, 16:47] Rakesh Biswas Gm Hod Sir Kims: The first line on 8/11 joining without having taken the temperature in two 4 hourly intervals is wrong! 

In such instances where there are absent dots we shouldn't join the distant dots

[11/11, 18:39] Rakesh Biswas Gm Hod Sir Kims: Please share the patient's lateral view of abdomen and biceps

[11/11, 20:25] Prathyusha: Ok sir


CASE 2 

PAJR link

https://chat.whatsapp.com/CIdLMBj7CGIBYEyAFvsvuj

Case report link

https://nvprathyusha100.blogspot.com/2023/11/65-yr-old-male-with-sob-fever-since-1.html?m=1



CASE 3

Case report link

https://nvprathyusha100.blogspot.com/2023/11/48-yr-male-with-ascites-pedal-edema.html?m=1

PAJR link

https://chat.whatsapp.com/ITRPEf7cMvU5FKyq5WtQaF


[24/11, 14:14] Rakesh Biswas Gm Hod Sir Kims: Symptom update? 

Daily weight?

[24/11, 14:17] Himaja Mam Gm Pg Kims: Patient still had abdominal discomfort sir

[24/11, 14:29] Rakesh Biswas Gm Hod Sir Kims: Please ask someone to start sharing his daily weight

[24/11, 14:29] Himaja Mam Gm Pg Kims: Yes sir measuring everyday already along with abdominal girth

[24/11, 14:29] Himaja Mam Gm Pg Kims: @⁨Prathyusha⁩ please share the trends here

[25/11, 13:15] Rakesh Biswas Gm Hod Sir Kims: Reduced his lasix today to 20 mg once daily as his pedal edema has reduced

[28/11, 06:54] Rakesh Biswas Gm Hod Sir Kims: Update?

[28/11, 09:14] Prathyusha: Vitals:

Bp-100/70mmhg

Pr- 82bpm

RR -19cpm

Temp- 98.6f

Examination:

Cvs - S1 S2 heard no murmurs

RS - BLAE, nvbs

CNS - NFND

P/A- distended

Abdominal girth- 86cm

Weight- 44.6kg

C/o - dry cough since yesterday night, abdominal discomfort, no fever spikes

Diagnosis - chronic liver disease

Treatment - 

Tab. Lasix 20mg po od

Syp. Lactulose 15 ml PO tid

Strict Alcohol abstinence.



CASE 4

Case report link

https://nvprathyusha100.blogspot.com/2023/11/65y-old-

male-with-burning-micturition.html?m=1

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