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 patient related information given by our intern.

(K. SAI RAGHU)

INTRODUCTION:

A 80yr old female, housewife by occupation came to casuality with 

chief complaints of : 

fever since 1 day.

loose stools since 1 day.

Vomitings since 1 day.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 1 day back then developed a high grade intermittent fever , associated with chills and rigors which decreased on using medication with no diurnal variation.

Patient had loose stools;2 in number,

vomitings,3 in number, non projectile, smelled like raw meat(as described by the attenders and patient)

No h/o pain abdomen 

no h/o cold and cough 

no h/o burning micturition or decreased urinary output

HISTORY OF PAST ILLNESS:

Patient is a k/c/o Hypertension since 4 years

and is on telmisartan 12.5mg

patient is not a k/c/o of DM, asthma epilepsy, TB.

PERSONAL HISTORY: 

bowel and bladder movements: normal.

appetite: normal.

non alcoholic.

non smoker. 

Family history : No significant family history

GENERAL EXAMINATION: 

patient is concious, coherent, cooperative well oriented to time and place 

VITALS:

TEMPERATURE: 103F.

PULSE RATE: 96bpm.

BP:130/60mmhg.

RR:26cpm.

SPO2:97% at room air. 

no pallor, icterus, cyanosis, clubbing, edema, generalised lymphadenopathy.

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

BAE+. 

NVBS.

CVS :

 S1S2 HEARD.

no thrills, no murmurs.


Per Abdomen:

Soft , non tender. 

no palpable mass.

bowel sounds heard.

CNS:

All superficial and deep reflexes are normal.

INVESTIGATIONS:

HEMOGRAM



BLOOD UREA


SERUM CREATININE


SERUM ELECTROLYTES


ECG


USG ABDOMEN


DIAGNOSIS: AKI secondary to acute gastroentritis.

TREATMENT:

ON DAY 01: 

Tab DOLO 650 mg TID.

Inj. MONOCEF 1gm IV/BD.

Inj. METROGYL 100ml IV/TID.

Tab. SPOROLAC-DS TID.

ON DAY 02:

Inj. PAN 40mg OD.

Inj. ZOFER 4mg IV/sos.

Tab DOLO 650 mg TID.

Inj. MONOCEF 1gm IV/BD.

Inj. METROGYL 100ml IV/TID.

Tab. SPOROLAC-DS TID.

Inj. NEOMOL 1gm IV/sos. {If temp more than 101*f}.








 




 

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