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A 24 year old female patient e log

 E-LOG GENERAL MEDICINE


Hi, This is K.Srinija , 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 

This is a case of 24 year old primi , homemaker presented to Casuality with the chief complaints of 

1) Suprapubic pain 4 days back

2)Fever since 4 days 

3) Vomitings since 2 days 

★HOPI

The patient is apparently asymptotic 4 days back. She developed suprapubic pain which lasted for one day for which she sought for consultation at a local hospital and was diagnosed to be having dengue fever

fever which is of high grade, intermittent associated with chills and rigors relieving on medication 

Vomitings of 2episodes/day immediately after consumption of food containing food particles, non bilious,non projectile, non foul smelling, non blood stained 

Burining micturition+

No history of loose stools, bleeding gums, rash, hematuria, malena 





★PAST HISTORY 


She is not a known case of diabetes, hypertension,asthma,cad,epilepsy


★PERSONAL HISTORY 


Diet-mixed 

APETITE -normal 

Sleep-adequate 

Bowel and bladder movements -normal

Addictions -none 


★FAMILY HISTORY 


not significant 


★MENSTRUAL HISTORY 


Age of menarche -16 years

Cycles- regular 3/28

Pads used per day -3

Bleeding,clotting- absent 


★GENERAL EXAMINATION


The patient is conscious coherent cooperative well oriented to time place and person 


She is moderately built and nourished 


Pallor - absent 

Icterus -absent 

Cyanosis-absent 

Clubbing -absent 

Edema -absent 

Lymphadenopathy -absent 


VITALS 


Temp-96F

BP-100/70

RR-16

PR - 82

Spo2 -99

GRBS -102


★SYSTEMIC EXAMINATION 


-CVS -s1s2 heard


-PA-vertical scar of 7-8 cm from xiphisternum to below,hypertrophied scar, non tender 






-RS-BAE+


-CNS- Higher motor functions intact 


★ DIAGNOSIS 

Primi with dengue NS1 +


★ INVESTIGATIONS 

Malarial parasite -ve







30/8/2022








31/8/2022



1/9/2022 












Rx 

O/E pt c/c/c 

Temp : 96 ° F 

PR : 104 BPM 

BP : 100/70 mmHg

CVS : S1S2 heard 

RS : BAE  

P/A : scar present 

CNS : NAD

- Inj . TAXIM 

- IVF 

.10 NS ; 10 RL 

- Strict I/O charting

-Inj ZOFER 

- Inj PAN 

- BP/PR/RR/Spoke charting 2nd hrly 


31/8/2022 



1/9/2022



2/9/2022


3/9/2022









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