GEN MED E LOG 1 SEPT

 E-LOG GENERAL MEDICINE

Hi, This is easha chandrika, 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 38 YRS OLD WITH VIRAL PYREXIA AND THROMBOCYTOPENIA 

Chief complaints:

Fever since 4days

Nausea and vomiting since 4days 

Headache since 3days 

HISTORY OF PRESENTING ILLNESS: 

The patient was apparently asymptomatic 4 days back and then he devloped:

Fever with associated chills and rigors

Retroorbital headache, vomiting which is non bilious immediately after intake of food ,vomitus contains food particles and non projectile for which he was admitted at area hospital

No h/o of bleeding gums

No h/o of hematemesis.                 

No h/o of burning micturition

No h/o of hematuria.   

No h/o of malena 

 HISTORY OF PAST ILLNESS:

N/k/o HTN,DM,TB,epilepsy,asthma,thyroid.

TREATMENT HISTORY:

Nil

PERSONAL HISTORY:

Occupation: driver

Diet: Mixed , Non vegetarian 

Appetite: decreased 

Sleep: adequate 

Bowels: Regular 

Known Allergies: No

No addictions.

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION

Patient is conscious and coherent

Well  built and well nourished

Well oriented to time, place and person. pallor present 

NoIcterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -no

No malnutrition 

No dehydration 

VITALS:

Temperature-afebrile

Pulse rate- 82/min

Respiratory rate- 16/min

BP- 120/80mmHg

SPO2 - 98% 

GRBS- 102mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Reflexes 

 Biceps Triceps Supinator Knee Ankle  

Right + + + + +           

Left + + + + +

INVESTIGATIONS


PROVISIONAL DIAGNOSIS :
Viral PYREXIA with THROMBOCYTOPENIA 
TREATMENT:
30/7:

1/8:



























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