GM - E-log



Greetings to one and all who are currently reading my blog. This is Mounika , a third semester medical student. 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 


Note : This is an ongoing case and will be updated as and when information is provided. This E-log has been made under the guidance of Dr. Harika. 

A 45 year old female patient came to the OPD with chief complaints of loose stools 20 episodes and vomiting 20 episodes


Past illness-

- no history of of DM/HTN/asthma /epilepsy / TB


Treatment history -

not significant


Personal history- 

-diet mixed 

-decreased appetite 

-regular bowel and bladder movements 

-no addictions


Family history-not significant


Vitals-

PR-84 bpm

BP-130/ 80 mm Hg

RR-16 cpm

GRBS- 110 mg/dl

Temperature-afebrile

SpO2-98%


General examination-

Pallor present 

no icterus, no clubbing, no cyanosis, no lymphadenopathy


Systemic examination-

CVS- S1, S2 heard

RS- BAE+

PA- soft, non-tender

CNS- NAD


 Provisional Diagnosis-

Acute gastroenteritis?


Investigations

On 07/08/2021



Treatment-

On 07 /08 /2021

• INJ. METROGYL  100ml / IV / TID

•INJ.CIPROFLOXACIN 500 mg /IV / BD

• INJ. ZOFER  4mg/IV/OD

• TAB. SPOROLAC  DS /PO/ TID

•INJ.PAN 40mg / IV/ OD


On 08/08 /2021

• INJ. METROGYL  100ml / IV / TID

•INJ.CIPROFLOXACIN 500 mg /IV / BD

• INJ. ZOFER  4mg/IV/OD

• TAB. SPOROLAC  DS /PO/ TID

•INJ.PAN 40mg / IV/ OD


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Hello all this is J. Mounika, a eighth semester student.This E Log depicts the patient centered approach to learning This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 80 year old male with  cough and difficulty in breathing since 2 years  An 80 year old male patien
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