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


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