GEN MED E-log -sept 01
Hi, This is Vaishnavi Manga, 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 38 YRS OLD WITH VIRAL PYREXIA AND THROMBOCYTOPENIA
Chief complaints:
Fever since 4days
Nausea and vomiting since 4days
Headache since 3days
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 4 days back and then he devloped:
Fever with associated chills and rigors
Retroorbital headache, vomiting which is non bilious immediately after intake of food ,vomitus contains food particles and non projectile for which he was admitted at area hospital
No h/o of bleeding gums
No h/o of hematemesis.
No h/o of burning micturition
No h/o of hematuria.
No h/o of malena
HISTORY OF PAST ILLNESS:
N/k/o HTN,DM,TB,epilepsy,asthma,thyroid.
TREATMENT HISTORY:
Nil
PERSONAL HISTORY:
Occupation: driver
Diet: Mixed , Non vegetarian
Appetite: decreased
Sleep: adequate
Bowels: Regular
Known Allergies: No
No addictions.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION
Patient is conscious and coherent
Well built and well nourished
Well oriented to time, place and person. pallor present
NoIcterus
No cyanosis
No clubbing
No lymphadenopathy
Oedema of feet -no
No malnutrition
No dehydration
VITALS:
Temperature-afebrile
Pulse rate- 82/min
Respiratory rate- 16/min
BP- 120/80mmHg
SPO2 - 98%
GRBS- 102mg%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM
Dyspnoea:No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
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
Comments
Post a Comment