General medicine (6)



Welcome and greetings to every one who are visiting my blog.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

Chief complaints: 
c/o fever sice 1 week
History of present illness: 
patient was apparently asymptomatic and then developed fever associated with chills which resolved on taking medication but fever reappeared associated with generalised weakness
Pain in the abdomen 2 days back associated with tightening of abdomen
No h/o vomitings and diarrhoea and no other complaints.
History of past illness: 
Not a k/c/o diabetes mellitus, hypertension, asthma, CVA, tuberculosis, CAD

Personal History
Married,
Diet- mixed
Appetite- normal
Sleep-adequate
Bowels and bladder movements- regular
No other habits

Family history
No case of diabetes, heart diseases, hypertension,stroke,cancer, tuberculosis and asthma

PHYSICAL EXAMINATION  
No pallor ,cyanosis, clubbing, lymphedenopathy and odema
Icterus is present

Vitals
Temperature: afebrile
Pulse rate: 98 beats / min
BP: 130/90mmhg
Respiration rate: 16cpm

 Systemic observation

Systemic examination: patient is examined in a well lit room with her consent

CVS :
No murmur 
No thrills 
S1 and S2 heart sounds heard
Rhythm - normal 
Volume - normal 

CNS:
patient is conscious, coherent and well oriented to time and place
speech is present
reflexes are normal

Abdomen:
Shape of abdomen is scaphoid
No tenderness
Liver and spleen not palpable
No free fluid
Bowel sounds heard

Respiratory system: 
BAE(+)
b/l IAA crepts(+)


Investigation: ultrasonography of chest
 
 

Provisional diagnosis: pleural effusion

Treatment:
Oxygen inhalation to maintain spo2 greater than 90%
Inj. Augmentin 1.2 gm i.v bd 
Inj. Pan 40 mg i.v of
Tab dilo 650 mg po tid






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