GENERAL MEDICINE E- LOG

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. 

Date of admission: 21/06/22

CHIEF COMPLAINT: 

A male patient aged 36 years came to the opd with chief complaints of

• Fever since 15 days 
• Weakness of b/l upper and lower limbs since 3 days 

HISTORY OF PRESENT ILLNESS: 

Patient came to the casuality with altered sensorium and quadriparesis. 

Patient was apparently asymptomatic 15 days back, then he presented with fever which was intermittent and relieved on medication. 

Patient had complaints of weakness of b/l upper limb and lower limb with decrease in tone and power since 3 days. 

Patient also had developmental delay of milestones in his childhood ( he walked at 6 years) 

Patient also had slurring of speech since 6 years of age 

Patient attained fine motor skills at the age 2 years, hearing and vision are normal since birth. 

HISTORY OF PAST ILLNESS: 

K/c/o Epilepsy ( since 6 months of age) 

Not a k/c/o HTN, DM , TB , CAD , asthma 

TREATMENT HISTORY: 

No relevant treatment history 

PERSONAL HISTORY: 

• Appetite is normal 
• Having mixed diet 
• Bowels regular 
• Micturition normal 
• Alcohol - teetotaler 
• No habit of smoking 
• No other habits/ addictions 

GENERAL EXMINATION:

Patient is conscious, coherent

Presence of pedal edema( non pitting edema) 

Absence of pallor, icterus, clubbing, cyanosis, lymphadenopathy.

                   

VITALS: 

1.Temperature: 101 F 

2.Pulse rate: 100 beats per min

3.Respiratory rate: 20 cycles per min 

4.BP: 150/80mm  Hg

5.SpO2: 98% @Room air 

6.GRBS: 156mg %  

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnea is absent 
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape of abdomen - scaphoid 
• No tenderness
• No palpable mass 
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient is conscious 
• Altered sensorium 
• Quadriparesis

                            RT                    LT 

TONE:       UL hypotonia        hypotonia 

              LL  hypotonia.      hypotonia 

POWER:   UL   2/5                   2/5

                  LL   0/5                   0/5 

REFLXES:   B   ++                    ++

                    T    ++                    ++

                    S    ++                    ++

                    K    ++                    ++

                    A    ++                    ++ 

                    P    Flexion            Flexion 

PROVISIONAL DIAGNOSIS: 

Fever with altered sensorium 

Sepsis

Leptospirosis+ 

Quadriparesis secondary to AMSAN 

Myositis 

AKI ( ? pre renal) 

Intellectual disability 

? Viral encephalitis 

INVESTIGATIONS: 

                              

Fever chart 

                              

ECG 

MRI report 

CHEST X-RAY 

         

                        

         

    

TREATMENT: 

On 21/06/22: 

1. INJ. MONOCEF 2gm/IV/BD 

2. INJ. DEXA 8mg/IV/TID 

3. INJ. DOXY 100mg/IV/BD 

4. IVF ONS @ 50ml/hr 

       ORL 

5. INJ. PAN 40mg/IV/OD 

6. TAB DOLO 650mg/RT/TID 

7. INJ. NEOMOL 1gm/IV/SOS 

8. Tepid sponging 

9. GRBS charting 6th hrly 

10. Monitor vitals 1hrly 

11. Temp charting 1 hrly 

On 22/06/22: 

1. INJ. Falcigo 120mg/IV/stat 

2. INJ. Acyclovir 500mg/IV/TID 

3. INJ. MONOCEF 2gm/IV/BD 

4. INJ. DEXA 8mg/IV/TID 

5. INJ. DOXY 100mg/IV/BD 

6. IVF ONS @ 50ml/hr 

             RL 

7. INJ. PAN 40mg/IV/OD 

8. TAB DOLO 650mg/RT/TID 

9.  INJ. NEOMOL 1gm/IV/SOS 

10. Tepid sponging 

11. GRBS charting 6th hrly 

12. Monitor vitals 1hrly 

13. Temp charting 1 hrly