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
SERUM CREATININE
SERUM ELECTROLYTES
ECG
USG ABDOMEN
Comments
Post a Comment