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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