E LOG GENERAL MEDICINE 

Hi, This is Kundana , a eighth 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

DATE OF ADMISSION : 11 TH September 2023

CHIEF COMPLAINTS 

. Headache since 1 month

. Cold since 10 days 


HISTORY OF PRESENTING ILLNESS 


A 62 YR OLD female daily labourer by occupation came to old with chief complaints of headache and cold, she is apparently asymptomatic a month ago

. she developed HEADACHE at parietal region which is dragging type ,radiating to neck ,spine and lower back ,pain is also seen at the site of paranasal sinuses when there is episodes of headache 

. Headache is associated with high grade fever associated with chills and riggers which is intermittent, no diurnal variation associated with cold and productive cough 

. c/o cough productive ( white sputum ) 

. no c/o chest pain ,SOB , orthopnea ,PND 

. no c/o sweating , palpitations 

. no c/o loose stools , nausea ,vomiting 

. no c/o burning micturition , decreased urine output 

. no c/o weight loss 


DAILY ROUTINE 


Patient wakes up at 5:00 am  , she does household chores till 7:00 am , she will have rice and curry for breakfast at 7:00 am , later she will go for field works till evening and she will have lunch at 2:00 pm same rice and curry she will do work till evening  and return home she will eat nothing in between later she will have dinner at 8:00 pm same rice and curry . later she will sleep , she has very low water intake , she is a occasional toddy drinker  20 yrs ago .


PAST HISTORY 

. not a k/c/o hypertension ,diabetes mellitus ,thyroid ,CAD , CVA , TB 


TREATMENT HISTORY 

. Hysterectomy 


FAMILY HISTORY 

. no significant family history 


PERSONAL HISTORY 

. diet-mixed 

. appetite- normal 

. sleep- adequate 

. bladder and bowel movements- regular 

. addictions- toddy drinker  20 yrs ( stopped for now )


MENSTRUAL HISTORY 

. Hysterectomy 20 yrs ago 


OBSTETRIC HISTORY 

.  Age of marriage -10 yrs 

. Age of first child birth -15 yrs 

. para - 4 

. no .of  living children -4 


GENERAL EXAMINATION 

. Patient is conscious , coherent , cooperative to time , place and person 

. Patient is moderately built and moderately nourished 

. no pallor 

. no icterus 

. no lymphadenopathy 

. no koilonychia 

. pedal edema 



VITALS 

. temperature - 95 degree Fahrenheit 

. blood pressure- 130/70 mm hg

. respiration rate -20 cycles/ min 

. pulse rate - 88 bpm 


CARDIO VASCULAR SYSTEM 

. S 1 and S2 heard

. no thrills 


RESPIRATORY SYSTEM 

.Troiser's sign- negative 

INSPECTION 

 Upper respiratory tract 

. no halitosis 

. oral hygiene -maintained 

. no oral thrush 

. no pharyngeal deposits 

. no tonsils present 

. no dental caries 

. no DNS 

. no nasal polyps 

. Sinus tenderness at time of headache 

Lower respiratory tract 

Inspection:

. chest is symmetrical 

. trachea-midline 

. no apical impulse seen 

. no drooping of shoulders,supraclavicular/infraclavicular hallowing , in tercoastal retractions/widening ,Harrisons sulcus, pacts carinatum/excavatum 

. no kyphoscoliosis , winging of scapula 

. no sinuses , scars ,dilated veins , nodules 

. chest movement with respiration is normal 

. no use of accessory muscles of respiration 


PALPATION 

.  all inspectory  findings are confirmed 

. trachea midline

. no intercostal tenderness 

.Tactile remits -present 

. Vocal fremitus- present 

. Chest movements- normal 

. chest expansion is seen 


PERCUSSION 

Right/left :

 . all regions have normal percussion findings 

 . no percussion tenderness 

AUSCULTATION 

. breath sounds - monophonic expiratory wheeze is observed 


CENTRAL NERVOUS SYSTEM 

. all higher mental functions are intact 

.right and left biceps- ++

. right and left triceps - +

. right and left supinator - +

. right and left knee reflexes - ++


ABDOMEN EXAMINATION 

. shape of abdomen looks like obese 

. no tenderness 

. normal hernial orifices

. liver and spleen are not palpable 

. bowel sounds present in right iliac fossa 

. no engorged veins , no visible epigastric palpations 


CLINICAL IMAGES 








INVESTIGATIONS:

 ECG







12/9/23


11/9/23



MALARIA TEST 


CHEST X RAY




BACTERIAL CULTURE SENSITIVITY REPORT 





FEVER CHART ON 12/9/23




FEVER CHART ON 13/9/23




PROVISIONAL DIAGNOSIS :

.Pyrexia

.Brochial asthma?


TREATMENT:

. IV fluids Normal saline- 75ml/hr 

. tab. levocetrizine

.syrup ascoryl 

. inj . amoxiclav 1.25 gm IV/TID 

. tab. azithromycin 500 mg

. tab Monteleukast 


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