GENERAL MEDICINE elog
Hi I am, A satyanarayana (roll no:12), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.
LIVERFUNCTION TEST
SERUM ELECTROLYTES
ELECTROLYTES OF SODIUM. AND POTASSIUM
A male patient of 80 years old came to opd with chief complaints of fever and weakness
CHIEF COMPLAINTS:
he came to opd with chief complaints of fever since 8 days and weakness since 3 days
HISTORY OF PRESENT ILLNESS:
the patient was apparently alright since 8 days back then he developed fever , chills inteemittently without any diurnal variations
After 2 days he had decreased apetite and throat pain
HISTORY OF PAST ILLNESS:
He was a patient of Diabetes mellitus 5 years back and hypertension 2 years back
He had hydrocele in his childhood
Personal history:
Diet- mixed
Appetite- decreased
Sleep- decreased
Bowel Movement’s - irregular
Addictions: He had smoking of Beedi
burning micturition is present
Family history :
No significant family history
Treatment history:
Diabetes 5 years back
HTN 2 years back
No asthma
No Blood transfusions
Hydrocele surgery has done
General examination;
Patient was conscious, coherent and cooperative
Moderately built and nourished
No pallor
No icterus
No cyanosis
clubbing of fingers present
No generalised lymphadenopathy
No Pedal oedema
INVESTIGATIONS
HEAMOGRAM
SEEUM. ELECTROLYTES AND CALCIUM
CLINICAL PICTURE
PROVISIONAL DIAGNOSIS
The patient had Hyperkalemia and hyponatremia
TREATMENT
Inj PIPTA 2.25 gm iv
Inj kcl 2 amps
Inj PAN 40 mg iv
Tab Doxy 100 mg
Inj optineuron 1 amp
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