A 40 year old male patient e log

E-LOG GENERAL MEDICINE

Hi, This is K.Srinija , a third 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 

A 40 year old male patient who is RTC driver by profession came to the OPD with chief complaints of :

   - fever since 3 days 

   - Headache since 2 days 

★ HISTORY OF PRESENT ILLNESS :

- Patient was apparently asymptomatic 3 days back , the he developed fever which is of high grade and associated with chills  , not associated with any diurnal variation 

- There is H/O headache since 2 days in frontal region which is of continuous  in nature 

- No H/O nausea , vomiting , loose stools , blurring of vision , abdominal distension , cough , cold 

★ HISTORY OF PAST ILLNESS

- No H/O DM , HTN , Bronchial asthma , TB , epilepsy 

★ TREATMENT HISTORY

- There is no usage of drugs as of now.

★ PERSONAL HISTORY 

- Married

- Mixed diet 

- Appetite - Normal

- Bowel movements - regular 

- Micturation - normal

- No known allergies 

- Ocassional alcoholic since 2 years [ last alcohol consumption 10 days back ]

★ FAMILY HISTORY 

- Not significant

★ GENERAL EXAMINATION 

- No - pallor / cyanosis /                                  lymphadenopathy / malnutrition /            icterus / clubbing / oedema /                     dehydration.

- Temperature : 99°F

- PR : 84/min

- RR : 16/min

- BP : 110/70 mmHg 

- Spo2 : 98% at room air 

- GRBS : 134mg/dl 

★ SYSTEMIC EXAMINATION

— CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

— ABDOMEN 

- Shape of abdomen : Obese

- No tenderness , palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are not palpable

- Bowel sounds : no 

— CNS 

- patient is conscious 

- speech is normal 

- No signs of meningeal irritation 

- No focal neurological defect is seen 

— Reflexes 

- plantars - flexor

                    INVESTIGATIONS 

             2/3/2022

         

              3/3/2022

                4/3/2022

★ PROVISIONAL DIAGNOSIS 

- Viral pyrexia 

★ TREATMENT

- Inj. OPTINEURON in 100 ml NS over 30 mins 

- T. PARACETAMOL 650 mg 

- IVF - NS / RL at 150 ml / hr 

- Strict I/O charting