GEN MED E LOG 3SEPT

 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 59 YRS OLD WITH  acute gastroenteritis 

Chief complaints:

fever since one day associated with chills and rigour  

also was suffering with loose stools since yesterday 

HOPI :

Patient was apparently asymptomatic 1day ago then he developed high grade fever which was associated with chills and rigours followed by several episodes of loose stools which were not blood stained and not foul smelling in each episode, the stools produced are yellow in colour ,large volume and of watery consistency .he also had  5 episodes of vomiting since yesterday. He was also discovered to be HIV positive in this hospital.

 there was no  history blood transfusion in the past,  and no history of needle prick, 

HISTORY OF PAST ILLNESS:

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

H/o of DM since 3 yrs

PREVIOUS HISTORY:

he presented with similar complaints in the past at this hospital
And was treated with
Tab. Pan 40 mg od for 7 days
Tab. METFORMIN 500 mg for 7 days
Tab.bescoules od for 7 days

TREATMENT HISTORY: 
METFORMIN for 3 months

PERSONAL HISTORY:

Appetite:normal

Diet:mixed

Bowel and bladder:regular 

Sleep: adequate 

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious and coherent

Moderately built and moderately nourished

Well oriented to time, place and person. 

No pallor

No Icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -no

No malnutrition 

No dehydration 

VITALS:

Temperature-101°f

Pulse rate- 112/min

Respiratory rate- 16/min

BP- 100/70mmHg

SPO2 - 98% 

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

BAE+

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

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

RBS

LFT

RFT

Cue

Hemogram
HbsAg


Anti hcv ab








Treatment:

Inj. Neomol 1gm, if stat (if temp more than 101f)
Tab. Sportscaster DS PO TID
Tab pan 40MG PO OD 
IV FLUIDS NS @50 ml/hr
Tab dolo 650 mpg

GRBS monitoring 6th hourly 
BP, PR monitoring 12th hourly 
temp monitoring 4th hourly  TID










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