General medicine elog

GM CASE

August 16,2021

V.Dedeepya

Roll no.- 136

Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data.


Case-1

  • THIS IS AN ONGOING CASE,WILL KEEP  UPDATING.

  • A 20 yrs old male patient daily laborer  by occupation came to casuality with cheif complaints  fever  since  yesterday , head ache since yesterday.

HISTORY OF PRESENT ILLNESS- 

  • cheif complaints of fever around yesterday night, high grade fever associated  with chill and rigor on , off relieved on medication , no history of cold, cough.
  • Head ache since yesterday 
  • pain in frontal region
  •  throbbing type of pain during episodes of fever
  • photophobia
  • phonophobia 
  • aggrevating with position variation, lacrimation(-), diplopia(-).
  • No history of nausea, vomiting, loose stools
  • No history of  chest pain, palpitation, syncopal attacks
  • No history of sob, orthopnea, palpitation
  • No history of pedal edema, facial puffiness
  • No history of burning micturition


PAST HISTORY-

  • No history of similar complaints in past 
  • Not a known case of dm, htn, tb, asthma , epilepsy
  • No history of previous surgeries and no history of previous blood transfusions


PERSONAL HISTORY-

  • Diet: mixed
  • Appetite: normal
  • Bowel, bladder habits : normal, regular
  • Not a smoker, alcoholic

VITALS-

  • Patient was C/C/C
  • PR :  84BPM.
  • RR : 18 CPM
  • BP : 9/60 mm of Hg. 
  • Spo2 : 99 % at RA. 
  • GRBS : 99 mg/dl 

 

 GENERAL EXAMINATION-

  • Patient is  thin built and malnourished. 
  • No pallor
  • No icterus, cyanosis, lymphadenopathy, Clubbing. 


SYSTEMIC EXAMINATION : 

  • CVS: S1, S2 heard, No murmurs. 
  •  RS:  Position of trachea : Central 
  •  BAE : +  
  •  NVBS Heard. 
  •  P/A : Soft, Non Tender, No palpable masses or swelling. 
  •  CNS : NAD. 


Diagnosis: dengue

15/8/21

ECG





FEVER CHART:











ESR-


Blood parasites-




Complete urine examination-




Biochemical investigations-











HIV rapid test-







16/8/21

Hemogram



TREATMENT-

15/08/21
Treatment given:
 1) Iv fluids
2) tab pcm 650 mg po/ tid
3) Inj neomol 1g/ iv/sos
4) Inj pan 40 mg / po/ od
5)Inj zofer 4 mg iv/sos

16/08/21
Treatment given:
 1) Iv fluids
2) tab pcm 650 mg po/ tid
3) Inj neomol 1g/ iv/sos
4) Inj pan 40 mg / po/ od
5)Inj zofer 4 mg iv/sos











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