GENERAL MEDICINE E-LOG

 42  SUPRIYA GAGIREDDY

3rd sem

Under the guidance of deepika mam


INTRODUCTION:

CASE HISTORY AND CLINICAL FINDINGS:

19 year female came to casuality with chief complaints of  2-3 episodes of vomitings ,which is non projectile .Non bilious associated with food particles.5 days back high grade fever.Intermittent ,relieved on medication.

Fever subsided 1 day back.


HISTORY OF PRESENT ILLNESS:

No H/o cold,cough,SOB,Headache

Pain abdomen,loose stools

Hematuria,Malena,Rash

No other complaints


PAST ILLNESS:

No H/O DM,HTN,ASTHMA,EPILEPSY,CAD,TB


PERSONAL HISTORY:

No significant personal history


FAMILY HISTORY:

No significant history


GENERAL EXAMINATION

VITALS:

TEMPERATURE:AFEBRILE

PR:96BPM

RR:18CPM

BP:100/70MMHG

SPO2:98%AT RA

GRBS:150MG/DL


SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD

RESPIRATORY SYSTEM:BAE+ NVBS HEARD

PER ABDOMEN:SOFT'

NON TENDER

CNS:NFND


INVESTIGATIONS:

ECG-NO SIGNIFICANT CHANGES

HEMOGRAM:1/8/2021

HB12.77GM

TLC4300 CELLS/CU MM

PLATELETS:54000CELLS /CU MM

RBC:NORMOCYTIC NORMOCHROMIC

HEMOGRAM:3/8/2021

HB:11.7GM

TLC-5000CELLS/CU MM

PLATELETS-1.2 LAKHS/CU MM

RBC-4.25MILLIONS/CU MM

PCV-34.8VOL%

BLOOD UREA

SERUM CREATININE

SERUM ELECTROLYTES

COMPLETE URINE EXAMINATION

LIVER FUNCTION TEST



CHEST X-RAY



                     

DIAGNOSIS:

FEVER WITH THROMBOCYTOPENIA

DENGUE NS1 POSITIVE


TREATMENT:

IVF-NS AND RL@100ml/HR CONTINOUS INFUSION

INJ.OPTINEURON 1 AMP IN 100ml NS IV/OD

TAB.PAN 40mg/OD

TAB.DOLO 500mg/BD


ADVICE ON DISCHARGE:

1]Plenty of oral fluids

2]TAB PAN 200mg OD-7 DAYS

3]TAB DOLO 500mg/sos

4]ZINCOVIT OD 7 days

Follow up

REVIEW SOS

When to obtain urgent care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY

DEPARTMENT

PREVENTIVE CARE

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE .DO NOT MISS MEDICATIONS.

DISCHARGE SUMMARY


Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021

NAME:G.SUPRIYA REDDY ROLL NO:42  Question 1: Competency tested for Peer to peer review and assessment : Please go through one particular answer of ten students in this link:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.  1 PULMONOGY   REVIEW: https://akash688.blogspot.com/2021/05/online-blended-bimonthly-assessmentmay.html   CASE:https://soumyanadella128eloggm.blogspot.com/2021/05/55-year-old-female-with-shortness-of.html   This is a case of Acute exacerbation of COPD associated with right heart failure and bronchiectasis.She is presented with shortness of breathe,genaralised weakness,facial puffiness,drowsiness and decreased urine output.She is a known case of Diabetes Mellitus for the past 8 years.She is a known case of Hypertension.The treatment for all the symptoms has gi
Read more

General medicine case discussion

Image
 G. Supriya reddy 42 67 year old male, sarpanch by occupation resident of nalgonda came with chief complaints of  cough since 1month and  breathlessness since 1month. HISTORY OF PRESENT ILLNESS Patient was apparently normal 1month back. Later he developed shortness of breath since 1 month. Increased on lying down, exertion, decreased on sitting position, taking rest. History of wheeze, cough since 1month with expectoration, mucoid, non foul smelling, No diurnal or postural variation, h/o decreased urine output since 1week.H/o pedal edema since 1week . Loss of appetite, no loss of weight. H/o chest pain, abdominal distension, Tendernrss, pain and fever.  HISTORY OF PAST ILLNESS H/o similar complaints  in past since 2years. Not a known case of Hypertension, diabetes mellitus, CAD.  No history of TB or covid 19 PERSONAL HISTORY APPETITE-Normal Mixed diet BOWELS-Regular MICTURITION-Decreased urine output since 1week ADDICTIONS-Occasional alcoholic, beedi 40/day FAMILY HISTORY No family his
Read more