GENERAL MEDICINE E- LOG

 NAME : G.PREETHI REDDY 

ROLL.NO : 43 

3rd SEM, 2019 BATCH 

This is online e log book to discuss our patients de identified health data shared after taking his/ her/ guardians consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e- log also reflects patients centered learning portfolio.  

INTRODUCTION :

CASE HISTORY AND CLINICAL FINDINGS:

A 14 year old female student  resident of nalgonda ame to Casuatly  on 1-08-2021 with chief complaints of 2-3 episodes of  vomitings since morning.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back then she developed fever which was high on grade , intermittent relieved on medication, fever subsided 1 day back. Now the patient had 2-3 episodes of vomitings, which was non projectile, non bilious, which contains food particles.  

 No H/O  cough, cold , SOB

 No H/O   pain abdomen , loose stools, malena

 No H/O rash

PAST ILLNESS:

NO H/O Diabetes, hypertension, Tuberculosis,asthama, epilepsy, thyroid, CAD, CVD

PERSONAL HISTORY:

Mixed diet

Normal appetite

Adequate sleep

Regular bladder and bowels movements

No addictions

FAMILY HISTORY:

No similar complaints in the family. No history of diabetes, hypertension,asthma, TB, CAD, CVD

GENERAL EXAMINATION:

Patient was conscious, coherent, co - operative. 

 Well oriented to time, place, and person. 

Moderately built and moderately nourished. 

No pallor

No clubbing

No cyanosis

No lympadenopathy

No edema

VITALS:

TEMPERATURE-AFEBRILE

PR-96BPM

RR-18CPM

BP-100/70 MM OF HG

SPO2-98 %AT RA

GRBS-150MG/DL

SYSTEMATIC EXAMINATION

PER ABDOMINAL EXAMINATION :

INSPECTION -

Shape - scaphoid

Umbilicus - central and inverted

Movements with respiration - equal in all quadrants rises with inspiration and falls during expiration .

No visible pulsations

No visible scars or sinuses seen

No engorged veins

PALPATION :

No local rise of temperature

No tenderness in any quadrants of abdomen, liver and spleen - impalpable ( no organomegaly) 

PERCUSSION :

Tympanic note

AUSCULTATION :

 Bowel sounds present 

CVS EXAMINATION :

S1, S2 heard

No murmurs

Apical impulse at 5 th intercostal space lateral to mid clavicular line

RESPIRATORY SYSTEM EXAMINATION :

Trachea - midline

Bilateral air entry present

Normal Vesicular breath sounds heard

No additional sounds

CNS EXAMINATION :

Gait - normal

Sensations - present

Cranial nerves - intact

Reflexes - preserved

PER ABDOMEN-

 SOFT NON TENDER

CNS- NFND 

INVESTIGATIONS:

ECG- NO SIGNIFICANT CHANGES

HEMOGRAM :1/8/2021

HB12.77GM

TLC4300 CELLS/CU MM

PLATELETS-54 000CELLS/ CU MM

RBC -NORMOCYTIC NORMOCHROMIC

HAEMOGRAM-3/8/2021

HB-11.7GM

TLC-5000 CELLS/CU MM

PLATELETS-1.2 LAKHS/CU MM

RBC-4.25 MILLIONS/ CU MM

PCV.34.8 VOL%

BLOOD UREA :14 mg/dl

SERUM CREATININE : 0.8 mg /dl

SERUM ELECTROLYTES ( Na , k, cl  ) 

SODIUM  : 135 mEq/L

  

POTTASIUM : 4.3mEq/L

CHLORIDE : 98mEq/L

COMPLETE URINE EXAMINATION 

COLOUR : pale yellow

 

APPEARANCE: clear

REACTION: acidic

SP GRAVITY: 1.010

ALBUMIN : Trace

SUGAR : Nil

BILE SALTS :Nil

BILE PIGMENTS: Nil

PUS CELLS :2-4

EPITHELIAL CELLS: 2-3

RED BLOOD CELLS : 3-4

CRYSTALS :Nil

CASTS :Nil

AMORPHOUS : Absent 

DEPOSITS 

OTHERS :Nil

LIVER FUNTION TEST

TOTAL BILLIRUBIN :0.75 mg / dl

DIRECT BILLIRUBIN : 0.20 mg / dl

SGOT (AST) :32 IUL

SGPT (ALT) :15 IUL

ALKALINE PHOSPHATE :201 IUL

TOTAL PROTEINS: 5.4mg / dl

ALBUMIN :3.0 mg/ dl

A/G RATIO : 1.29 mg /dl

BLOOD UREA 

SERUM CREATININE

SERUM ELECTROLYTES 

COMPLETE URINE EXAMINATION 

LIVER FUNTION TEST:

                                                                     CHEST X-RAY

DIAGNOSIS:

FEVER WITH THROMBOCYTOPENIA

TREATMENT:

IVF -NS AND RL@100 ml/ HR CONTINOUS INFUSION 

INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD 

TAB.PAN 40 MG /OD 

TAB.DOLO 500MG/BD