General medicine elog

E-LOG GENERAL MEDICINE

Hi, This is Kundana , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

A 45 year old male with fever

Chief complaints:

A 45 year old male came to opd with fever ,farmer by occupation residing at cherlapally

• Fever since 7 days

• Slurring of speech since 4 days

•Burning  micturition since 4 days

History of present illness:

The patient is apparently asymptomatic 2 days before he admitting hospital , He came to hospital with complaints of fever with chills after admitting into hospital he developed slurring of speech and burning micturition.

Day to day routine:

•He used to wake up daily at around 4:00 am

• He completes his mandatory things and go to his farm at 6:00 am and takes a cup of tea between

•He will have his breakfast (rice) at 10:00 am

• He will have his lunch(rice) at 2:00 pm

• He will take some liquid like food at evenings 

• He will complete his dinner at 8:00 pm and take some alcohol daily nearly( 180ml)

• He will sleep at 9:00 pm after dinner

Past illness:

• Patient was apparently asymptomatic 2 yrs back.

• Then his appetite increased for which he came to our  hospital and diagnosed with Diabetes.

• He used oral hypoglycemic agents for the first six months and from past one and half year he is on insulin

• History of increased urine output since 2 years

• History of weight loss(25 kgs) since 2 yrs

Personal history:

• Diet:mixed 

• Appetite: increased

• Sleep: adequate 

•Bowel (loose stools)and bladder(irregular)

•Addictions: Alcohol since 25 yrs (180ml/day)

Family history:No significant family history

Drug history :No history of allergy to any drugs 

GENERAL EXAMINATION

• Patient was conscious coherent and cooperative

• Poorly  built and nourished 









• Pallor present

• No Icterus

• No cyanosis

• No clubbing

• No generalized lymphadenopathy

• Bilateral pedal edema (pitting) present

Vitals:

•Temperature: 97

• Pulse rate: 100 

• Respiration rate:20

• Bp:110/80 mm/Hg

• SpO2:98%

• GRBS:578


SYSTEMIC EXAMINATION


CVS:

•No thrills and murmurs

• S1 & S2 heard

Respiratory system

• Dyspnoea ,wheeze absent 

• centrally placed trachea 

• Normal vesicular breath sounds 

Abdomen

• Scaphoid shaped abdomen

• No tenderness

• No palpable mass

• No free fluid

• No bruits

• Non palpable liver

• Non palpable spleen

• Bowel sounds present

CNS

• Level of consciousness- drowsy

• Slurred speech

• Neck stiffness present

• No kernings sign

•Power - 4/5 in all 4 limbs

• Cranial nerves intact

INVESTIGATIONS:

























3 dialysis sessions are done

31/07/2022
1/08/2022
3/08/2022



DIAGNOSIS 
Urosepsis with Diabetes

 TREATMENT:



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