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.

CHIEF COMPLAINTS:

A 75 yrs old male patient came to casuality with cheif complaints of shortness of breath,loose stools and fever since 4 days.

HISTORY OF PRESENTING ILLNESS:

  • Shortness of breath
  • Loose stools
  • Low grade Fever
PAST HISTORY:
  • The patient had a history of TB seven years ago and took medication.
  • A known case of hypertension.
  • Had renal failure 1 year back and is on conservative treatment for 4 months
PERSONAL HISTORY:
  • H/o smoking and alcohol but stopped a year ago but now stopped.
  • Not a known case of DM.

VITALS:

  • Patient was C/C/C
  • PR :  97BPM.
  • RR : 27 CPM
  • BP : 120/90 mm of Hg. 
  • Spo2 : 90 % at RA. 
  • GRBS : 120 mg/dl 

GENERAL EXAMINATION-

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

SYSTEMIC EXAMINATION:

  • Cvs: S1 and S2 heard,no murmurs
  • Resp: inspiratory crepts in all areas and wheezing.
  • CNS : NFD
  • P/A: soft
PROVISIONAL DIAGNOSIS:
  • COPD
  • Community acquired pneumonia
BIOCHEMICAL INVESTIGATIONS:

ECG:


URINE PROTIEN/ CREATININE RATIO


STOOL FOR OCCULT BLOOD:

  
COMPLETE URINE EXAMINATION:


PROTHROMBIN TIME:


RETICULOCYTE COUNT:


PERIPHERAL SMEAR:


M.P STRIP TEST:



 
ABG:


HEMOGRAM:

 
ANTI HCV ANTIBODIES: 


HIV RAPID TEST 

HBsAG RAPID TEST


BACTERIAL CULTURE


LIVER FUNCTION TEST


SERUM ELECTROLYTES:


BLOOD UREA:


RANDOM BLOOD SUGAR:


TREATMENT:






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