GENERAL MEDICINE E-LOG

 

GM E-LOG


Greetings to one and all who are currently reading my blog. This is I.Himavathsa , a third semester medical student. 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


Note : This is an ongoing case and will be updated as and when information is provided. This E-log has been made under the guidance of Dr. Harika 


A 70 year old female patient came to the OPD with chief complaints of fever since 3 days and polyuria since 3 days.

Patient was apparently asymptomatic 3 days back then she developed fever associated with chills and rigor present throughout the day relieved after taking medication

No diurnal variation 

No C/O cough ,shortness of breath 

C/O headache since 3 days(differ type) 

C/O decreased appetite since 3 days nausea vomiting. 


Patient was taken to hatangur 3 days back given some medication and was told she has high sugar (300 mg/dl) 

no H/O chest pain

no H/O palpitation

no H/O burning micturition

no H/O pedal edema


PAST ILLNESS-

k/c/o DM, HTN since 3 months. 


TREATMENT HISTORY-

T. METFORMIN 500 mg/ po/BD.

T. ATEN 50/ po/ BD. 

- has no treatment history of asthma, TB


PERSONAL HISTORY-

Is married and daily wage labourer 

appetite -normal 

vegetarian

Bowel and bladder movements are regular

No known allergies

addictions-


FAMILY HISTORY-


• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases. 


GENERAL EXAMINATION-



• Pallor - no

• No cyanosis, icterus

• No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition. 

• Dehydration - mild


Vitals :


• PR - 98bpm ( irregular) 

• RR - 22 cycles/min

• BP - 110/80 mmHg

• Temp. 103.3°F

• GRBS - 110 mg/dl

• SPO2- 81%


SYSTEMIC EXAMINATION-


A. Cardiovascular system :


• S1, S2 are heard

• No thrills and no cardiac murmurs


B. Respiratory system:


• No dyspnoea, no wheezing

• Position of trachea - central

• Breath sounds - Vesicular

• crypts 


C. Per Abdominal Examination:


A• Shape of abdomen - scaphoid

• No Tenderness 

• No palpable mass , free fluids, bruits

• Liver, spleen not palpable

• there are Bowel sounds


D. Central Nervous system Examination:


• Pt is conscious

• Speech normal

• No neck stiffness, kerning's sign. 


DIAGNOSIS-

Viral pyrexia (left lower lobe pneumonia).


INVESTIGATION 


On 07/08/2021.











Ultra sound:-














Fever chart:-

From 07/08/21 to 09/08/21 



On 09/08/21.









Treatment:-

Day 1 :- 07/08/2021

    1) IVF - RL
                        } @50ml/hr
                - NS

    2) TAB.PAN - 40mg/PO/OD

    3) TAB.ZOFER - 4mg/IV/SOS 

    4) TAB.DOLO - 650mg/PO/DD 

                1------ 1-------1

    5) TAB.AZITHROMYCIN- 500mg/PO/OD 

                1------X-------X

    6) ING. NEOMOL -100 ml/IV/SOS 

                                 (If Temp>101.1F°)
   
     

   7) O2 Inhalation if SP O2 < 90% of room air.

   
  

    Day2:- 08/08/2021

   1)   IVF - RL
                           } @75ml/hr
                   - NS

   2) INJ.MONOCEF 1ml/IV/SOS

   3) TAB.AZITHROMYCIN- 500mg/PO/OD 

                1------X-------X

   4) TAB.PAN - 40mg/PO/OD

   5) TAB.ZOFER - 4mg/IV/SOS 

   6) TAB.DOLO - 650mg/PO/DD 

                1------ 1-------1


Day 3:- 09/08/2021

     1) IVF - RL
                           } @75ml/hr
                   - NS
 
     2) INJ.MONOCEF 1ml/IV/SOS

     3) TAB.AZITHROMYCIN- 500mg/PO/OD 

     4) TAB.PAN - 40mg/PO/OD

     5) TAB.ZOFER - 4mg/IV/SOS 

     6) TAB.DOLO - 650mg/PO/TID

     7) GRBS Charting 6th hrly

     8) O2 Inhalation if SP O2 < 90% of room                air

     9) Temperature charting 1 hrly.

     10) Strict I/O Charting.












































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