A 45yr old female patients with complaint of fever since 4 days

A 45yr old female patients with complaint of fever since 4 days

ROHITH SOMANI

Roll no.147

This is 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 patients 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 comment box is welcome .


 

I’ve 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.

CASE DISCUSSION:

A 45yr old female resident of kulapalli Village came to OPD with complaints of

-Fever since 4days
-c/o loose stools since yesterday

HOPI

Patient was apparently asymptomatic 4days
Back then developed fever associated with chills and rigors, intermittent type,no aggrevating factors.
-c/o decreased appetite since 4 days
-c/o loose stools,4 episodes,watery,non blood stained
-c/o SOB(grade-2) since 4days,more since morning but presently there is decreased SOB
-no c/o chest pain, palpitations,orthopnea,PND
-no c/o pain abdomen, burning micturition.

PAST HISTORY 

not a k/c/o: DM, HTN, Asthma, epilepsy, CAD, TB,CVD

PERSONAL HISTORY

Appetite decreased since 4days

Diet-mixed type

Bowel and bladder - regular
No addictions
No history of allergy to food or drugs

GENERAL EXAMINATION

Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor,icterus ,cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals: 
temperature:98.4F
Pulse rate: 80bpm
Resp rate:18cpm
BP:90/50mmhg
Spo2:99%

SYSTEMIC EXAMINATION

CVS
S1S2 heard
No cardiac murmurs
Apex beat heard at 5th ICS

Respiratory system

Normal vesicular breath sounds heard
Position of trachea - central

Abdomen

Inspection: shape - scaphoid
Umbilicus - central and inverted
No visible scars,engorged veins
All abdominal quadrants moving equally on inspiration and expiration.

Palpation: no tenderness present
Liver and spleen not palpable

Percussion: resonant note heard all over abdomen on percussion

Auscultation: bowel sounds are heard on auscultation

CNS

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++



Investigation






RFT on 14/6/23

Urea-35
Creatine - 0.8
Uric acid- 2.8
Ca+2- 10.2
Na+ -136
K+ - 3.3
Cl- 106

LFT on 14/6/23

Total bilirubin -0.7
Direct bilirubin -0.19
SGOT-20
SGPT-25
ALP-199
Albumin-3.10
A/G-0.79

Hemogram on 14/6/23

Hb-12.0
TLC-5,900
Neutrophil-62
Lymphocytes -31
PCV-34.6
MCHC-34.7
RBC-3.9
Platelet-2.66

RBS on 14/6/23

99mg/dl

SERUM ELECTROLYTES ON 15/6/23

Na+-141
K+-3.4
Cl- 104

 HEMOGRAM ON 15/6/23


Hb-11.6
TLC-5,200
Neutrophil-50
Lymphocytes -45
PCV-33.3
MCHC-34.8
RBC-3.8
Platelet-2.33


USG abdomen :

impression:no sonological abnormalities found









Provisional diagnosis

?Acute gastroenteritis

Treatment:

1)i.v NS@50ml /HR stat
2) inj.Neomol 1gm/SOS ( if temp >101f)
3)tab.dolo 650mg po/bd
4)tab.sporolac-ds po/bd
5)tab.zofer po/sos





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