Gm e-log

K Mahendra roll no 56 8th Sem

 This elog depicts the patient centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients I centered learning portfolio.


55 year old male came to opd with chief complaints of fever and yellowish discoloration of eyes and tongue( jaundice) since 15days 

  HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 15 days ago when he developed fever which was insidious in onset, low grade, gradually progressive in nature, associated with chills and rigors.

No hlo loose stools, vomitings

Pedal edema was noted by patient 2 days ago, pitting type

No h/o decreased urine output or burning micturation.

H/o cough since 1 day, non productive, dry cough.

No hlo chest pain, palpitations and sob

H/o yellowish discoloration of eyes and tongue since 15 days

No h/o bleeding per rectum, haematuria .






PAST HISTORY


K/c/o Diabetis mellitus II since 6 years, on unknown medication

N/k/c/o HTN, BA ,CVA , CAD , TB, Epilepsy

H/O Leprosy ? Hypopigmented patches ,7 months ago.



Medication one month ago?

No surgical history

H/o Blood transfusion , 5 days back. No reactions. Indications?


PERSONAL HISTORY

Married

Mixed diet

Decreased Appetite

Regular Bowel and bladder

No allergies 

Alcoholic since 20 years, stopped one year ago.


FAMILY HISTORY

Not significant 


GENERAL EXAMINATION:


Patient is conscious, coherent and co-operative,well oriented to time,place and person.

Moderately build and well nourished.

Examination was done in a well lit room.

Pedal edema + ( grade 2)

Icterus +

No pallor, cyanosis,clubbing,lymphadenopathy

Vitals

PR- 96 bpm

BP- 130/80 mm Hg

RR- 16 cpm

Temp -100 F

GRBS - 144 mg/dl








SYSTEMIC EXAMINATION



ABDOMEN 

Inspection

Shape - Slightly distention.

Umbilicus - Everted

Equal movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars , sinuses 



Palpation

Soft, non tender


Auscultation

Bowel sounds heard



RESPIRATORY SYSTEM 

Bilateral air entry present

B/L Crepts in ISA,IAA, Right Infra Mammary

Vocal resonance decreased



CVS EXAMINATION 

S1 S2 heard( Slightly muffled), no murmurs




CNS EXAMINATION 

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

INVESTIGATIONS

31/10/23


















1 Nov 

2 NOV






3 NOV




PROVISIONAL DIAGNOSIS

? Drug induced hepatitis

K/c/o Leprosy

K/c/o DM II

Dapsone syndrome?

With anaemia 


TREATMENT

INJ.PIPTAZ 2.25 iv/ TID

INJ. Lactulose 10 mg PO/BD

INJ.Actrapid s/c according to GRBS

T. Dolo 650 mg PO/TID

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