GENERAL MEDICINE E-LOG

SUPRIYA GAGIREDDY 42

Hi,I am supriya 5th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia.

CASE

A 60 year old female , daily labourer by occupation, resident of juhugudem came to OPD with chief complaints of 
Chief complaints

1.Yellowish discoloration of eyes since 25 days. 

2. Generalised weakness since 25 days. 

3.fever since 25days


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back and developed a fever associated with burning micturition and yellowish discoloration of eyes for which she came to our hospital and advised admission but attenders doesn't want to get admitted. 
Then she used some herbal medication on every monday for 2 weeks(I.e.. She used medication for 2 times) during which she skipped antihypertensives and antidiabetics. 
Then she was fine until yesterday night and slept having dinner. Then she wake up at 2:00 AM for urination but she has difficulty in passing urine and couldn't pass urine. So she slept again and woke up at 5:00 AM and started developing sweating and weakness. 

HISTORY OF PAST ILLNESS

K/c/o hypertension and DM since 6 years and on irregular medication
No History of CAD, TB, asthma, epilepsy. 


TREATMENT HISTORY

For diabetes and hypertension she was using medications since 6 years . 
For HTN: Tab. AMLONG 5 mg PO/OD
For DM: Tab. METFORMIN 500mg.,Tab. GLIMIPIRIDE 

PERSONAL HISTORY

Occupation : Daily laborer 
Diet : mixed
Appetite: normal
Bowel habits: irregular
Micturition: Abnormal
Addictions: toddy drinker occasionally but stopped after diagnosed with HTN and DM

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION

Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built

VITALS 

Temperature: 98 °F
Pulse rate: 84 per min
Respiratory rate: 18 per min
BP: 140/90 
SpO2: 99% 
GRBS: 54mg%

PHYSICAL EXAMINATION

Pallor : absent
Icterus : present
Cyanosis : absent
Clubbing of fingers / toes : absent
Lymphadenopathy : absent
Edema : absent

SYSTEMIC EXAMINATION

CVS
S1 and S2 heard
No murmurs

RESPIRATORY SYSTEM
Dyspnoea : no
No Wheezing
Postion of trachea: central

ABDOMEN 
Shape of abdomen: obese
No free fluid
Liver and spleen are not palpable
Bowel sounds are normal

CNS
Conscious 
Speech : Normal
No signs of neck stiffness
There is no sign of meningeal irritation
Glasgow scale 15/15

INVESTIGATIONS

On 01/07/2022

Complete Urine Examination

Serum Chloride

Hemogram

Anti HCV antibodies

HBsAg Rapid

HIV 1/2 Rapid test

Liver function test

Serum Creatinine


Serum potassium

Blood Urea

On 18/07/2022

2D Echo

ECG



Ultrasound

PROVISIONAL DIAGNOSIS
?Viral Hepatitis

TREATMENT 

On 18/07/2022
IVF-DNS 50ml
INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml PO

On 19/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
TAB. UDILIV 300 mg PO/BD
Tab. WYSOLONE 10mg
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm IV/BDS
TAB. RIFAGUT 550 mg Po/BD

On 20/07/2022

INJ- PANTOP 40 mg IV/OD
INJ. ZOFER 4 mg IV
Syp. LACTULOSE 25 ml 
INJ. NEOMOL 1gm IV/BDS
TAB. RIFAGUT 550 mg Po/BD
TAB. PCM 500 mg PO/BD
INJ. TRENEXA 500 mg IV/STAT
SYP. AROSTROZYME 25ml PO/TID

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

GENERAL MEDICINE E-LOG

Image
  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:NORMOCYTI
Read more