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 


Chief complaints:
  • High grade fever 
  • generalized weakness
History of presenting illness: 

Patient is apparently from 2 days ago. Then he developed generalized weakness since 2 days, patient is unable to do his daily routine activities.                           

  • he had history of giddiness since yesterday
  • he developed fever which is high grade , intermittent , relieved on medication
  • history of fall 2 times
  • history of loss of  consciousness
  • shortness of breath
  • chest pain present
  • palpitations present
  • history of travelling under sun for 2 days 
Daily routine
Patient wakes up at 6 am then gets freshened up, takes tea at 7 am eats breakfast at 8 am and then goes to work as a daily labourer and then comes back home at 1 pm takes lunch then sleeps for 2 hours then takes tea at 6 pm and eats dinner at 8 30 pm and goes to sleep by 9 30 pm.

History of past illness:

he is a known case of diabetes mellitus type 2
he had history of lower limb filariasis 20 years back
no history of TB , asthma ,epiliepsy 
he used antihypertensives







Personal history

He takes mixed diet with normal appetite and has regular bowel and bladder movements.
He takes alcohol daily since 1 year.

Family history

No significant family history

General examination

Pallor is present.
No features indicating the presence of icterus, cyanosis, clubbing, edema lymphadenopathy











Fever chart








SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION

INSPECTION:

No distention,No scars
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION:

No local rise of temperature, Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.

PERCUSSION:

Liver span is 12cm, No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.

AUSCULTATION:

Bowel sounds present.


CVS- S1 and S2 heart sounds heard. 

RS- Bilateral air entry is present, normal vesicular breath sounds heard


CNS EXAMINATION

Right Handed person, uneducated 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE 26/30

speech : muffled, unclear

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:
Intact

MOTOR EXAMINATION:        
               Right Left
   
BULK UL Normal Normal
            LL Normal Normal

TONE UL  Normal  Normal
             LL Normal Normal

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


REFLEXES
                           Right                   Left
BICEPS               +++                     +++
TRICEPS             ++                        ++
SUPINATOR        ++                        ++
KNEE                   +++                      +++
ANKLE                 ++                       ++
PLANTAR           flexor                  flexor


SENSORY EXAMINATION: intact

PROVISIONAL DIAGNOSIS

VIRAL PYREXIA 
DM 2 SINCE 20 YRS


INVESTIGATIONS


ECG


                                             X RAY CHEST




SEROLOGY
HBsAG- Positive
HIV, HCV- Negative



USG Abdomen




CBP 6/6/23




HEMOGRAM 7/6/23



LFT 6/6/23


CUE 6/6/23

6/6/23


FBS- 70mg/dl
PLBS-167mg/dl

Blood urea-37mg/dl
Serum creatinine- 1.8mg/dl

Serum electrolytes-6/6/23


MRI DONE ON 10/6/23


Treatment

Inj.Monocef 1gm IV/BD
Inj.Doxycycline 200 mg iv/bd
Tab.Dolo 650mg PO/TID
Inj.Neomol 1gm IV/SOS if temp more than 101 F










Comments

Post a Comment

Popular posts from this blog

Image
40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS    December 06, 2023   40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS  ** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified  health data shared, AFTER taking his/her/guardian's signed informed consent. Here, in this series of blogs, we discuss our various 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 also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to de
Read more

A 55 yr old male with lower back pain

Image
​ 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 Chief complaints:    Patient complains of shortness of breath , fever and lower back ache . shortness of breath since 10 days Lower back pain simce 10 days  History of present illness:   The patient is apparently asymptomatic one month ago , then he developed shortness of breath  shortness of breath: insidious onset , grade-2 (NYHA) , gradually progressive  History of orthopnea, PND, cough present No history of chest pain , cold  Decreased urine output since one month Thin stream , poor flow, increased frequency, hesitency sensations present, burning micturition present, but no pain during micturition Pain: at lower back , dull boring typ
Read more