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.

      






Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE E-log

Image
 NAME : A SANVITH ROLL NO : 09 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. DOA: 24/06/2022 Question : A 38 year old male farmer by occupation and came to the opd with chief complaints of pain on the right leg. HISTORY OF PRESENT ILLNESS Patient was asymptomatic one month back and he devoloped pain on the Right leg which is slow in Onset and he visited RMP doctor and Doctor gave medicine the Onset Of Pain is increased and he visited sparsha  hospital and doctor suggested to take x-ray and MRI scan and he gave medicines the patient decreased p ain with medicine  and he devoloped lot of Pain and  went to homeopathy 1 month back and with medic
Read more

GENERAL MEDICINE E-log

Image
NAME:A sanvith ROLL NO:09  Welcome and greetings to every one who are visiting my blog. This is A sanvith of 8th semester.  This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. CHIEF COMPLAINTS : Generalized weakness since 1year Premature ejaculation since 1year. HISTORY OF PRESENTING ILLNESS : Patient was apparently asymptomatic 1year back and then he developed weakness associated with semen in urine. And also developed polyuria(nocturia two to three times at night) patient also history has h/o premature ejaculation 2-3minutes since 1year. HISTORY OF PAST ILLNESS :  Patient was  n/k/c/o go fever, pain abdomen, burning micturition, vomitings,loose
Read more

GENERAL MEDICINE E-log

Image
 NAME : A SANVITH ROLL NO : 09 DATE OF ADMISSION:29/06/2022 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. QUESTION  A 57 year old male patient came to the hospital with cheif complaints of fever since 6days and pain abdomen since 4days History of present illness  Patient was apparently asymptomatic 6days back then he developed fever which is intermittent type (morning and night) and 4days back he developed severe pain in abdomen in epigastric and right hypochondrium region and nausea after 2hours of dinner not associated with vomitings and cough for which he admitted in hospital early morning where symptoms are not subsided and therefore cam
Read more