GENERAL MEDICINE E-LOG

NAME :G.AKSHARA KRUTHI ,3 RD SEM 

UNDER THE GUIDENCE OF DEEPIKA MAM 

INTRODUCTION :

CASE HISTORY AND CLINICAL FINDINGS:

19Y/F CAME TO CASUALTY WTH CHIEF COMPLANTS OF 2-3EPISODES OF VOMITINGS

WHICH IS NON PROJECTLE, NON BILIOUS ASSOCIATED WITH FOOD PARTICLES

5 DAYS BACK HIGH GRADE FEVER, INTERMITTENT, RELIEVED ON MEDICATON

FEVER SUBSIDED 1 DAY BACK

HISTORY OF PRESENT ILLNESS :NO H/O COLD, COUGH, SOB,.HEADACHE, 

PAINABDOMEN,LO0SE STOOLS 

HEMATURIA,MALENA, RASH

NO OTHER COMPLAINS


PAST ILLNESS. NO HO DM ,HTN, ASTHMA, EPLEPSY, CAD, TB.

 PERSONAL  HISTORY:

NO SIGNIFICANT PERSONAL HISTORY


FAMILY HISTORY : NO SIGNIFICANT HISTORY 

  GENERAL  EXAMINATION :

VITALS:

TEMPERATURE-AFEBRILE

PR-96BPM

RR-18CPM

BP-100/70 MM OF HG

SPO2-98 %AT RA

GRBS-150MG/DL


SYSTEMIC EXAMINATON

CVS- S1,S2 HEARD 


RESPIRATORY SYSTEM - BAE + 

                                          NVBS HEARD

PER ABDOMEN- SOFT 

                             NON TENDER

CNS- NFND

INVESTIGATIONS:

ECG- NO SIGNIFICANT CHANGES

HEMOGRAM :1/8/2021

HB12.77GM

TLC4300 CELLS/CU MM

PLATELETS-54 000CELLS/ CU MM

RBC -NORMOCYTIC NORMOCHROMIC


HEMOGRAM-3/8/2021

HB-11.7GM

TLC-5000 CELLS/CU MM

PLATELETS-1.2 LAKHS/CU MM

RBC-4.25 MILLIONS/ CU MM

PCV.34.8 VOL%

BLOOD UREA 

SERUM CREATININE

SERUM ELECTROLYTES 

COMPLETE URINE EXAMINATION 

LIVER FUNTION TEST


CHEST X-RAY


DIAGNOSIS: FEVER WITH THROMBOCYTOPENIA
                      DENGUE NS1 POSITIVE

TREATMENT:
IVF -NS AND RL@100 ml/ HR CONTINOUS INFUSION 
INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD 
TAB.PAN 40 MG /OD 
TAB.DOLO 500MG/BD 

ADVICE ON DISCHARGE:

1}Plenty of oral fluids.
2}TAB PAN 200mg OD- 7days.
3}TAB DOLO 500mg/ sos.
4}ZINCOVIT OD 7days.

Follow Up

REVIEW SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
                                         ATTEND EMERGENCY DEPARTMENT

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE.DONOT MISS MEDICATIONS.


Discharge summary : 

CASE HISTORY AND CLINICAL FINDINGS:

19Y/F CAME TO CASUALTY WTH CHIEF COMPLANTS OF 2-3EPISODES OF VOMITINGS

WHICH IS NON PROJECTLE, NON BILIOUS ASSOCIATED WITH FOOD PARTICLES

5 DAYS BACK HIGH GRADE FEVER, INTERMITTENT, RELIEVED ON MEDICATON

FEVER SUBSIDED 1 DAY BACK

HISTORY OF PRESENT ILLNESS :NO H/O COLD, COUGH, SOB,.HEADACHE, 

PAINABDOMEN,LO0SE STOOLS 

HEMATURIA,MALENA, RASH

NO OTHER COMPLAINS


PAST ILLNESS. NO HO DM ,HTN, ASTHMA, EPLEPSY, CAD, TB.

 PERSONAL  HISTORY:

NO SIGNIFICANT PERSONAL HISTORY


FAMILY HISTORY : NO SIGNIFICANT HISTORY 

  GENERAL  EXAMINATION :

VITALS:

TEMPERATURE-AFEBRILE

PR-96BPM

RR-18CPM

BP-100/70 MM OF HG

SPO2-98 %AT RA

GRBS-150MG/DL


SYSTEMIC EXAMINATON

CVS- S1,S2 HEARD 


RESPIRATORY SYSTEM - BAE + 

                                          NVBS HEARD

PER ABDOMEN- SOFT 

                             NON TENDER

CNS- NFND

INVESTIGATIONS:

ECG- NO SIGNIFICANT CHANGES

HEMOGRAM :1/8/2021

HB12.77GM

TLC4300 CELLS/CU MM

PLATELETS-54 000CELLS/ CU MM

RBC -NORMOCYTIC NORMOCHROMIC


HEMOGRAM-3/8/2021

HB-11.7GM

TLC-5000 CELLS/CU MM

PLATELETS-1.2 LAKHS/CU MM

RBC-4.25 MILLIONS/ CU MM

PCV.34.8 VOL%

BLOOD UREA 

SERUM CREATININE

SERUM ELECTROLYTES 

COMPLETE URINE EXAMINATION 

LIVER FUNTION TEST


CHEST X-RAY


DIAGNOSIS: FEVER WITH THROMBOCYTOPENIA
                      DENGUE NS1 POSITIVE

TREATMENT:
IVF -NS AND RL@100 ml/ HR CONTINOUS INFUSION 
INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD 
TAB.PAN 40 MG /OD 
TAB.DOLO 500MG/BD 

ADVICE ON DISCHARGE:

1}Plenty of oral fluids.
2}TAB PAN 200mg OD- 7days.
3}TAB DOLO 500mg/ sos.
4}ZINCOVIT OD 7days.

Follow Up

REVIEW SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
                                         ATTEND EMERGENCY DEPARTMENT

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE.DONOT MISS MEDICATIONS.

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