GENERAL MEDICINE E-LOG

 NAME: Anga sanvith 

ROLL NO: 09

GENERAL MEDICINE E-LOG

Hello everyone myself I am Anga Sanvith from 3rd semester. below is the E-LOG of the patient who was approached with health problem. Below is the information about the patient given by our peer.


INTRODUCTION:

A 45-year old male presented to the casuality in the state of altered sensorium since 1 day.

HISTORY OF PRESENT ILLNESS:

  • Difficulty in walking.
  • Decreased appetite since 15 days.
  • Constipation since 5 days.
  • Fever and pedal edema-pitting, extending up to knees since 3 days.
  • Vomiting since 2 days.
HISTORY OF PAST ILLNESS:

  • 6 months back patient was apparently asymptomatic until he had B/L pedal edema for which he went to a local hospital where he was diagnosed with hypothyroidism? CLD and given symptomatic treatment.

  • 1.5 month back he had history of fever and dry cough weight loss from then.

  • 1 month back he has tingling and numbness in B/L lower limb till ankle.

  • 15 days back he was admitted in our hospital with those C/O tingling and numbness in B/L lower limb till ankle associated with slippage of footwear. 

  • Not a K/C/O DM/HTN/asthma/epilepsy/LAD/TB.

TREATMENT HISTORY:

  • He was on T.THYRONORM 25mcg for hypothyroidism.
PERSNOL HISTORY:

  • He was chronic alcoholic since 20 years.
FAMILY HISTORY:

  • No familiar history.
GENERAL EXAMINATION:

  • Patient was in altered sensorium.
  • Not oriented to T/P/P
  • GCS- E2V2M4.
  • Moderately built and moderately nourished.
  • no pallor and icterus.
  • B/L pedal edema.
  • No lymphadenopathy.
VITALS:

  • PULSE RATE: 86 BPM.
  • BP: 90/50mmhg.
  • SPO2: 98% on RA.
CARDIOVASCULAR SYSTEM:

S1S2- HEARD.

No murmurs.

RESPIRATORY SYSTEM:

BAE: +VE.

NVBS: Heard.

P/A: soft, non tender.

CENTRAL NERVOUS SYSTEM:

  • NECK: stiffness +VE.
  • TONE: Hypotonia in B/L LL.
  • POWER: Left UL-3/5  
                        Left UL-1/5

                        Right UL and LL-0/5.

  • REFLEXES: 2+, planter: withdrawal.

INVESTIGATIONS:

COMPLETE BLOOD PICTURE 


COMPLETE URINE EXAMINATION


APTT


PROTHROMBIN TIME


TROPONIN-1


BLOOD SUGAR-RANDOM


SERUM ELECTROLYTES (Na, K, cl)


ARTERIAL BLOOD GAS


BLOOD UREA


CREATININE


LIVER FUNCTION TEST


REPORT



CHEST RADIOGRAPHY





MRI



CSF ANALYSIS





PROVISIONAL DIAGNOSIS:
  • Meningitis-bacterial/TB.
  • CVA.
  • Hyponatremia.
  • Chronic nutritional hypoalbunemia.
TREATMENT:
  1. Inj CEFTRIAXON 2mg × Iv ×BD.
                                 1-×-1

     2. Inj DEXMETHASONE 8mg × IV × BD.
   
                                  1-×-1

     3. Inj PAN 40mg × IV × OD.

     4.IVF NS 100ml/hr

     5.Inj THIAMINE 1 amp in 100ml NS/IV/OD.

     6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.
   
     7.Temp charting 4th hourly.
      
     8.TAB PCM 650mg × RT × sos.

      






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