GENERAL MEDICINE E-LOG


SUPRIYA GAGIREDDY 42

Hi,I am supriya 8th 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


CHEIF COMPLAINTS:


 28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days

HOPI:

patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation 

No history of malena, hematuria

No complaints of chest, pain, cough, cold

No complaints of burning micturition

No complaints of loose stools, nausea, vomiting



PAST HISTORY :

Not a known case of hypertension, diabetes, thyroid, CAD CVA TB



PERSONAL HISTORY:

Appetite: normal

Diet: mixed

Addictions: no

Sleep: adequate

bowel regular 

General examination:

Pt is conscious, coherent, cooperative

No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy 



Vitals :

Bp :120/90mm hg

PR:78bpm

Temp:97.8

RR: 21 cpm

Systemic examination:

Per Abdomen:

Shape of abdomen-distended

Umbilicus -inverted

Abdomen moves accordingly with respiration.

 No sinuses/scars
Abdomen is soft,diffused tenderness
No free fluid

Hernial orifices-Normal

No organomegaly

Bowel sounds- present 

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central 

Tactile vocal
Fremitus                   Right                              Left

Supraclavicular          N                                   N

Infraclavicular           N                                   N

Mammary                   N                                  N

Inframammary          N                                  N  

Axillary                        N                               N

Infraaxillary               N                                N

Suprascapular           N                                N

Infrascapular            N                                N


-Percussion                Right                          Left

Supraclavicular          R                                R

Infraclavicular           R                                R

Mammary                   R                               R

Inframammary          R                               R

Axillary                        R                             R

Infraaxillary               R                             R

Suprascapular           R                              R

Infrascapular             R                             R

R-Resonant 

Auscultation        Right                          left              

Supraclavicular     NVBS                                  NVBS

Infraclavicular       NVBS                                 NVBS

Mammary               NVBS                                NVBS

Inframammary      NVBS                                NVBS  

Axillary                    NVBS                            NVBS

Infraaxillary            NVBS                            NVBS

Suprascapular        NVBS                           NVBS

Infrascapular         NVBS                          NVBS



Central Nervous system:

Conscious
Cranial nervers -normal

Tone                 Rt                  Lf 
UL                     N                   N
LL                      N                   N

Power               Rt                  Lf

UL                    5/5                 5/5
LL                     5/5                 5/5

Fine touch       Rt                  Lf 
UL                     N                   N
LL                      N                   N

Reflexes.          Rt.                 Lt
Biceps               ++                 ++
Triceps             ++                  ++
Supinator        ++                  ++
Knee                 ++                  ++
Ankle                ++                  ++


PROVISIONAL DIAGNOSIS :DENGUE FEVER (NS1 &IGM POSITIVE)


Investigations:



Hemogram

21/10/23

22/10/23

23/10/23

24/10/23

25/10/23

Hb

19.1

17.5

16.8

15.6

15.2

TLC

4000

4000

5200

5600

5600

RBC COUNT

6.19

5.81

5.81

5.37

5.22

PLATELET COUNT

18000

40000

20000

28000

52000

Hemogram
21/10/23

22/10/23

23/10/23

24/10/23

25/10/23

Hb

19.1

17.5

16.8

15.6

15.2

TLC

4000

4000

5200

5600

5600

RBC COUNT

6.19

5.81

5.81

5.37

5.22

PLATELET COUNT

18000

40000

20000

28000

52000
ECG
Color doppler
ultrasound
TREATMENT:
S/P ONE SDP TRANSFUSION ON 23/10/23
1. IV FLUIDS @75 ML/HR
2.INJ TRAMADOL 1AMPULE IN 100 ML NS IV
3.TAB PCM 650MG PO/SOS



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