GENERAL MEDICINE ELOG

 This is the online elog platform where there will be case discussion .Which improves basics of learning like how to take a case,howt to the patient,how to take history of the patient,how to examine the patient,and by considering what factors we have to diagnose,and the treatment that should be followed.

UNDER THE GUIDENCE OF SAI DEEPIKA MA'AM (INTERN)

INTRODUCTION:

CASE And CLINICAL FINDINGS:

   A 14 yr old female came to casualty with the chief complaints of 

-2to 3 eposodes of vomitings
-which is non projectile,non bilious
associated with food particles
5days back HIGH GRADE FEVER,
INTERMITTENT, relieved on medication
Fever subsided 1 day back.

History of present illness:

• No H/o of cold ,cough,SOB , headache
• Pain abdomen,
    loose stools, 
    hematuria,
    Malena
    rash.
No other complains

PAST ILLNESS:

No H/o DM,HTN,ASTHMA, EPILEPSY,CAD,TB

PERSONAL HISTORY:

No significant personal history

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION

Vitals:

Temperature - affebrile
PR- 96bpm
RR-18 cpm
BP-100/70 mm of Hg
SPO2-98% AT RA
GRBS-150 mg /do

Systemic Examination:

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 7
HAEMOGRAM
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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