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
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