General medicine ICU patient

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

A 80yrs old female patient from nalgonda housewife by occupation came to hospital with chief complaints of-

1.fever since 3 days

2.pain in abdomen on and off since one  month

3.burning micturition since 1 month


History of presenting illness:

Patient was apparently asymptomatic one month back then she developed pain in abdomen which was diffuse,non radiating associated with burning micturition,then she started having fever since 3 days which is high grade not associated with cough,cold and headache


History of past illness:

H/o # ?rt neck of femur fracture 4yrs back since then she managed to walk with walker

H/o #? Lt knee fracture 2yrs back since then she was bed ridden

Not a k/c/o of DM,HTN, epilepsy,asthma.


Treatment history:

No treatment history


Personal history:

Diet:mixed

Appetite:normal

Sleep : normal

Bowel and bladder: irregular 

Micturition: burning

H/o no addiction


Family history: not significant


GENERAL EXAMINATION:

No pallor



No icterus






No cyanosis

No clubbing

No lymphadenopathy

No edema





Vitals:

Temperature: 103F

pulse rate: 102 bpm

Respiratory rate:20cpm

bp:130/80mmHg 

GRBS:123mg%

Systemic examination:

Cvs:

S1 s2 heard no murmer

Respiratory:

No dyspnoea no wheeze position of trachea centre

Vesicular breath sound heard

Abdomen:

shape of abdomen obese, diffuse tenderness present 



CNS:

level of consciousness drowsy

Speech normal

Provisional diagnosis :

Community acquired pneumonia

Renal calculi

Mild hydrocephalus

Investigations: 

                          USG REPORT 



ANTI HCV ANTIBODIES 


HEMOGRAM:


ERYTHROCYTE SEDIMENTATION RATE:


BLOOD SUGAR RANDOM 


RFT


COMPLETE URINE EXAMINATION 


LIVER FUNCTION TEST


BLOOD SUGAR FASTING 


HIV RAPID TEST


SERUM OSMOLARITY


URINE PROTEIN CREATININE RATIO


BLOOD GROUPING AND RH TYPE


C REACTIVE PROTEIN 


HBS AG RAPID 


POST LUNCH BLOOD SUGAR


ABG




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