36 year old female with fever, vomittings and abdominal pain

 E-LOG GENERAL MEDICINE

Hi, I'm  Moovika , 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

Case scenario -

36 year old female, housewife by profession came to OPD with chief complaints of

•  fever since 1 week 
• Pain in the abdomen since 5 days 
• Vomiting since 3 days 

History of presenting illness-

Patient was apparently asymptomatic 1 week back, then she developed fever which was associated with chills and rigor 

This was followed by pain in abdomen which developed 5 days back in the epigastric region  which was sudden in onset and it was  dragging type 

Vomiting since 3 days which was non bilious and non projectile - 5 to 6 episodes a day 

History of past illness-

No history of DM, Hypertension, Tuberculosis, Asthma, Epilepsy

Hysterectomy was done 17 years ago 

Personal History-

Married

Mixed diet

Bowel movements normal

Micturition normal

No known allergies 

FAMILY HISTORY 

- not significant

 

GENERAL EXAMINATION 

- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing 

- BP - 90/80 mmg

- PR - 106 /min

-RR- 18 /min

- SPo2 -98% at RT

- Temp - 101 degree F

SYSTEMIC EXAMINATION

— CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath sounds : vesicular

— ABDOMEN 

- Shape of abdomen : obese

- tenderness present , no palpable mass 

- Hernial orrifices : Normal 

- No fluids 

- Liver and Spleen are not palpable

- Bowel sounds : yes

— CNS 

- patient is conscious 

- speech is normal 

- No signs of meningeal irritation 

- Higher motor functions intact 

Investigations -

Provisional diagnosis -

Viral pyrexia

Treatment-

8/8/22

•IVF - 20 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Tab. Naproxen 250 /TID

• Inj. Pcm 1g/IV/SOS if temp >=101F

•Tab. Pcm 650mg po/ TID

•Tab. Vertin 16mg po/ BD

9/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD 

• Inj. Pcm 1g/IV/SOS if temp >=102F

•Tab. Pcm 650mg po/TD

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml 

10/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD 

• Inj. Pcm 1g/IV/SOS if temp >102F

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml 

Gen med e log

 E-LOG GENERAL MEDICINE

Hi, This is Moovika, 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.

A 66 YEAR OLD WITH END STAGE RENAL DISEASE

Chief complaints:

A 66 year old male hailed from suryapet presented to the OPD with chief complaints of:

Bilateral pedal edema since 3 months. SOB since 3 months. Puffiness of face. Body aches

HOPI:

Patients was apparently asymptomatic 12 years ago .

He developed chest pain and was diagnosed with IHD: S/P CABG was done.

At the same time he was diagnosed with hypertension and DM 2 for which he started taking medicine.

Then he was fine till 3 months back and started developing B/L pedal edema which is pitting type and was extended up to knees and Grade 2-3 SOB.

He went to hospital and was diagnosed with kidney disease .

Then he was planned for hemodialysis with right IJV.

1st dialysis on-23/07/22

2nd dialysis on-24/07/22

Loss of weight about 15kgs since 2 months

PAST HISTORY:

DM since 12 years. HTN since 12 years. SOB

FAMILY HISTORY: Nil significant

PERSONAL HISTORY:

Mixed diet

Appetite-normal

Sleep-inadequate 

Bowel and bladder habits-normal

No allergies

No addictions

GENERAL EXAMINATION:

VITALS:

Patient was conscious and coherent

Well built

Temp:afebrile

Pulse rate: 72 bpm

RR: 14 cpm

BP: 110/70

Spo2: 99%

GE:

•No pallor/icterus/clubbing/cyanosis/lymphadenopathy

Investigations

ECG presentation