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