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