60yr OLD MALE WITH DEEP VEIN THROMBOSIS WITH ACITROM OVERDOSE OLD PULMONARY KOCHS

UNIT 4 ADMISSION ON 4/2/21
Interns
K Mohitha
M supriya
Kota Soumya
Sanjay
Amrutha
Dr Durga krishna(PGY1)
Dr Ajith(PGY2)
Dr Laxma reddy(PGY3)
Dr Manasa (PGY3)
Dr Vijayalaxmi(asst prof)

This is an online E log book to discuss our patient's 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 learning portfolio and your valuable inputs on the comment box is welcome.

60 year old male sheperd by occupation
C/o blood in sputum while coughing from 2 days
C/o pain in the right lower limb while walking from 3 months 

HOPI
patient was apparently alright 3 months back later he developed right lower limb pain(calf pain) while walking  and swelling of right lower limb
He was able to walk only for about 2meters for which he went to private hospital and was diagnosed with DVT in right lower limb- Proximal ATV and PTV upto external iliac vein 2 and half months back
Patient was started Tab ACITROM 1mg
The dose was adjusted according to PT ,APPT ,INR values
Later the dose was increased to Tab ACITROM 3mg/PO/OD which he used for 12 days and stopped the medication as he thought hemoptysis is due to the medication
Now he can walk for about 100meters without any pain ,Swelling is present
He is a K/C/O pulmonary kOCHS 9years ,used ATT for about 6months
Not a k/c/o DM,HTN,Asthma,epilepsy ,CAD
O/E 
Patient is conscious ,coherent,cooperative
Temp-afebrile,PR-92bpm,BP-130/80mm hg 
SpO2-99%at RA

S/E 
CVS-s1s2 +
RS-BAE+
P/A-soft ,non tender
CNS-NAD

Diagnosis-Deep vein thrombosis with upper GI Bleeding with  ?ACITROM overdose
Old pulmonary kochs
Treatment
1)INJ PAN 40MG IV/BD
2)INJ OPTINEURON in 100ml NS/IV/OD
3)Planing for upper GI endoscopy today

Investigations 
PT- 17
APTT-33
INR-1.2


SOAP UPDATE 6/2/21
1) TAB ACITROM 1MG/PO/OD
2)TAB PAN 40MG /PO/OD
3)TAB ZINCOVIT PO/OD



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