E log August - 2

E-LOG GENERAL MEDICINE
Hi, This is Rithika, 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

16 year old female patients with loose motions.

CHIEF COMPLAINTS 

A 16 year old female  came to the OPD with chief complaints of loose motions since 3 days.


History of 2 episodes of fever  .1 St episode on Thursday night and 2 nd episode on Friday morning. Which relieved with medication


HISTORY OF PRESENT ILLNESS 

The patient was apparently normal 3 days back ,and consumed outside food ( Manchuria) on Thursday afternoon (2pm) and has loose motions since 3 days.

The motions are bilious in nature and no blood in the stools.

The patient has 2 episodes of fever. 1st episode on Thursday night and 2 nd episode on Friday morning.

No abdominal pain, vomitings.


PAST HISTORY

No similar complaints in the past are seen.

Not a k/c/o Tuberculosis, Diabetes mellitus, epilepsy, cardiovascular disease, coronary artery disease.

History of anaemia 1 year back. Blood transfusion done (3bags).

History of asthma since age of 3 years and using medication.

 TREATMENT HISTORY

Using asthma medication since the age of 3 years.

Blood transfusion done 1 year back(3bags).

PERSONAL HISTORY

Appetite is normal.

Mixed diet .

Bowel movements irregular.

No burning micturition.

Sleep normal.

No allergies.

No addictions.

FAMILY HISTORY

No history of Diabetes mellitus, Tuberculosis, epilepsy, coronary artery disease, cardiovascular disease , asthma.

GENERAL EXAMINATION

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

Height: 

Weight: 28kgs

No pallor.

No icterus.

No cyanosis.

No lymphadenopathy.

No pedal edema .

Malnutrition is seen .

Mild dehydration is seen.


VITALS 

Temperature: 98.3C/F.

Pulse rate :120 beats per min.

Blood pressure: systole 80mm HG

SPO2:97 percentage

Respiratory rate : 25 cycles per minute

GRBS :112 mg.


SYSTEMIC EXAMINATION

Cardiovascular system

No thrills.

S1,S2 heard.km

No murmurs heard.

RESPIRATORY SYSTEM


No dyspnoea.

No wheeze.

Position of trachea: central 

Breathe sounds vesicular

ABDOMINAL EXAMINATION

Shape of abdomen: scaphoid.

Tenderness: present in right iliac fossa.

No palpable mass 

No hepatomegaly.

No spleenomegaly.

Hernial orifices normal 

CENTRAL NERVOUS SYSTEM

Conscious

Speech normal 

Cranial nerves : normal 

Motor system: normal 

Sensory system: normal.

PROVISIONAL DIAGNOSIS

Acute gastroenteritis

INVESTIGATIONS.

Complete blood picture





Complete urine examination



Erthryocyte sedimentation rate.




TFR graph sheet




Stool for occult culture



C reactive protein



Renal function test



Liver function test 



Ultrasonography



Bacterial culture and sensitivity



Colour Doppler 2D Echo 



ECG 





DIFFRENTIAL DIAGNOSIS : ACUTE GASTROENTERITIS

TREATMENT


6/8/22

 I.V fluids: NS and RL 75ml /hr.

Tab ZOFER 4 mg po/sos.

Tab PANTOP 40mg po/od 

Tab PARACETAMOL 650mg po/sos

Tab SPOROLAC DS po/tid.

7/8/22


I.V fluids: NS and RL 75ml /hr.

Tab ZOFER 4 mg po/sos.

Tab PANTOP 40mg po/od 

Tab PARACETAMOL 650mg po/sos

Tab SPOROLAC DS po/tid.

Plenty of water

1 ORS sachet in 1 litre of water


8/8/22


I.V fluids: NS and RL 75ml /hr.

Tab ZOFER 4 mg po/sos.

Tab PANTOP 40mg po/od 

Tab PARACETAMOL 650mg po/sos

Tab SPOROLAC DS po/tid.

Plenty of water

1 ORS sachet in 1 litre of 


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