GENERAL MEDICINE ELOG-4

Hi,Iam Harichandanarao 3rd sem medical student.Thus is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio



A 32 yr old female patient,works in shopping mall by occupation came with complaints of severe back pain since 3 months,vomiting,TB since 3 months on medication

HISTORY OF PRESENT ILLNESS:
patient was asymptomatic before covid vaccine,in november,after that developed back pain and on medication,but the pain progressive increased from march dragging type of pain.vomiting present since may with in 30min after intake of food which contains food particles diffuculty during swallowing,non bilious,no history of burning micturition

PAST HISTORY:
Diagnosed with left renal abscess and was managed conservatively  and TB since 3 months and on medication[ATT MARCH]
No history of any surgery

 
PERSONAL HISTORY:
 No diabetes,no hypertension,no asthma
no known allergies
non vegetarian diet
 
FAMILY HISTORY :
No TB

GENERAL EXAMINATION:
presence of   pallor,no icterus,clubbing of finger/toes 
oedema of feed lymphadenopathy
 
TEMP:96
RR:20
BP:100/60
SPO2:98%
GRBS:109mg/dl
 

 
SYSTEMIC EXAMINATION:
CNS patient is concious,coherent,co-operative 
speech is normal
 
RESPIRATORY SYSTEM:
no dyspnea
no wheeze
position of trachea is normal 
 
CVS:
cardiac sounds present
nop cardiac murmer
 
ABDOMEN:
Scaphoid abdomen,no tenderness,no palapable mass,no free fluid and fruits,not palpable liver and spleen bowel sounds present 
 
DIAGNOSIS:
Left renal abscess
pottis spine 


INVESTIGATION:
USG KUB
NCCT KUB 
 
 TREATMENT:
i pan     40mg iv/od
i papfaz 4.5mg iv/bd
i amakain 500mg iv/od
i.neomol  7m iv/tid
i.piptaz  40mg iv/od
metrogyl 500mg iv/bd
i.zofer    4mg iv/od
i.tromadol 100mg iv/sos

 
 

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