General Medicine E-log
A 65 year old female came to the OPD with complaints of lower back pain radiating to the lower limbs.
Chief Complaints:
A 65 year old female home maker, resident of Tummalaguda came to the OPD with complaints of
Severe lower back pain radiating to the legs since 6 days, fever since 1 week and shortness of breath.
History of presenting illness:
The patient was apparently asymptomatic 1 week ago when she felt pain in the lower back which was insidious in onset, gradually progressive, radiating to the lower limbs upto her knees and of stabbing type.
She also had low grade fever since a week that was intermittent and not associated with chills and rigor. It was relieved on medication. She also has shortness of breath (grade II). She has constipation since 4 days.
Past history:
History of
HTN since 10 years for which she was on medication.
Osteoarthritis since 10 years.
N/K/C/O DM, TB, asthma, thyroid disorders, epilepsy, CAD or CVA
Personal history:
Diet: mixed
Appetite : decreased
Sleep: adequate
Bowel movements: constipated since 4 days
Bladder: decreased urine output since 1 year
No known allergies or addictions
Family history:
Not significant
General Examination:
Patient is moderately built and moderately nourished.
She is conscious, coherent and cooperative
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or pedal Odema is seen.
Vitals:
Temperature: afebrile
PR: 78 bpm
RR: 18 cpm
BP: 120/70 mmHg
Systemic Examination:
CNS:
Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact
CVS:
S1, S2 were heard
No Murmurs
No thrills
Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
Crepitus heard on right side
No thrills
Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
Crepitus heard on right side
Per Abdomen:
Soft, non tender, no organomegaly
Hernial orifices are normal
No palpable masses
Bowel sounds were heard
Provisional diagnosis: Pyrexia under evaluation
Investigations:
ECG
USG
2D echo
Final diagnosis:
Treatment given (present course in the hospital):
29/07/23
1. Inj. NEOMOL 1g IV/SOS (if temp > 101 degrees)
2. Inj. OPTINEUTRON 1amp in 100 ml NS/IV/BD
3. Inj MONOCEF 1g/IV/BD
4. Tab. PARACETAMOL 650mg PO/BD
5. Tab. AMLONG AT 5/50 PO/OD
6. Monitor vitals
7. Inform SOS
8. Inj. TRAMADOL 1amp in 100 ml NS IV/BD
30/07/23
1. Inj MONOCEF 1g/IV/BD
2. Inj. OPTINEUTRON 1amp in 100 ml NS/IV/BD
3. Inj. NEOMOL 1g IV/SOS
4. Tab. AMLONG AT 5/50 PO/OD
31/07/23
1. Inj MONOCEF 1g/IV/BD
2. Inj. OPTINEUTRON 1amp in 100 ml NS/IV/BD
3. Inj. NEOMOL 1g IV/SOS
4. Tab. AMLONG AT 5/50 PO/OD
01/08/23
1. Inj MONOCEF 1g/IV/BD
2. Inj. OPTINEUTRON 1amp in 100 ml NS/IV/BD
3. Inj. NEOMOL 1g IV/SOS
4. Tab. AMLONG AT 5/50 PO/OD
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