General medicine e-log

 E-LOG GENERAL MEDICINE

Hi, This is Nikitha , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

40y old female came admitted in hospital  

Chief complaints:

H/o fever since 4days which is of low grade intermittent with no chills &rigor

H/o of nausea since 3days

H/o of food intake since 3days

H/o of generalized weakness nd loose stools since a day 

HOPI

Patient was apparently asymptomatic 5days back

 On 4th low grade fever, generalized weakness associated with cough consulted local hospital for hypotension started on fluids and discharged.she had nausea which resulted on food intake, history of loose stool of 4to 5 episodes watery, foul smelling ,non mucoid ,non bloody not associated with abdominal pain

Cough  since 4 days productive whitish ,scanty.

No myalgia,joint point , retro orbital pain ,chest pain ,or burning micturition.

HISTORY OF PAST ILLNESS:

N/k/o HTN,TB,epilepsy,asthma,thyroid.

H/o of dust allergy 

TREATMENT HISTORY: 

Nil

PERSONAL HISTORY:

Appetite: decreased

Diet:mixed

Bowel and bladder:regular 

Sleep: adequate 

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious and coherent

Moderately built and moderately nourished

Well oriented to time, place and person. 

No pallor

No Icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -no

No malnutrition 

No dehydration 

VITALS:

Temperature-101°f

Pulse rate- 112/min

Respiratory rate- 16/min

BP- 100/70mmHg

SPO2 - 96% 

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

BAE+

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Reflexes 

Biceps Triceps Supinator Knee Ankle  

Right + + + + +           

Left + + + + +

INVESTIGATIONS





TREATMENT:
7/9:






Provisional Diagnosis:-
Viral pyrexia 

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