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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