37 yr old female with fever since 1 month and Shortness of breath since 3 days

 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 have 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


M.Abhignya

Roll.No. 83

37 year old female farmer by occupation  came to OPD with complains of & Breathing difficulty 3 days.


HOPI:


Patient was apparently asymptomatic one month ago then she had Fever Low-grade , Insidious onset, Intermittent ,not associated with chills and Rigor aggreviated at Nights ,Relieved with Medications

associated with Generalised Myalgia and Giddiness.

 Clo Burning Micturition

SOB Grade-II Dyspnea on Exertion 

C/O Headache, dragging type radiating to Neck and Hands

 C/O Painful defecation.

Clo Tingling sensation in both Lower limbs

 Nocturia present

No C/O Polyuria ,polydypsia,polyphagia

 No C/O cough; cold; chest pain

No c/o Sweating; Palpitations; orthopnea,PND

No c/o loose stools, Nausea; Vomitings

No C/O loss of appetite, weight loss, Insomnia 

C/o weight gain since 3 months.


Past history:


*K/c/o  of DM-II since 3 years

Started on Tab GLIMI  1 MG & metformin 500 mg PO/OD since  5 month

*Not a K/C/0 HTN,TB,ASTHMA,CAD, EPILEPSY

*Underwent LSCS 18 yrs ago


Toddy drinker, last binge 2-3 days ago


No significant family history


ON Examination Patient is

 conscious,Coherent & Cooperative 

BP: 110/70mmHg

PR:76 bpm

RR:18cpm

Sp02:98% at RA

GRBS:220mg/dl

Temp:98.6F







No pallor,icterus, cyanosis, clubbing,lymphedenopathy,pedal edema





CVS: S1 S2 present,no murmurs 

RIS: BAE present,NVBS

PIA:Soft ,NT

CNS :NFND


Investigations 






USG Abdomen 



2D echo




ECG



CXR



Diagnosis:

PYREXIA secondary to ?UTI


Treatment:


1. Plenty of oral fluids

2.Tab.DOLO 650mg PO TID

3.Tab.GLIMI M1 PO OD

4.Tab.MVT PO OD

5.GRBS Monitoring


Comments

Post a Comment

Popular posts from this blog

60 y old female with anasarca and vomitings

Image
  This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. I have 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 a diagnosis and treatment plan. Abhignya.    Roll. No 71 On 28.02.22 Patient presented with complaints of  - Bilateral pedal edema  -vomitings  Patient was apparently asymptomatic 6months back then she noticed pedal edema till ankel which was pitting type.  It was on and off .  But since 1 month this pitting
Read more

38 yr old male with Chronic Liver Disease

Image
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 solveb 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 is welcome. Abhignya  Roll no.83 A 38 year old male car driver by occupation and a known case of alcoholic hepatitis came to OPD with cheif complaints of 10-15 episodes of vomitings since one day  History of presenting illness:-   Patient was apparently asymptomatic 9 months back then he developed jaundice  with yellowish discoloration of eyes and urine , associated with pruritis  for which he went for evaluation and upper GI endoscopy was done on 12/7/22 and given impression of low
Read more

49 yr female with burning sensation in epigastric region since 5 months

Image
  In 2010 she went for a routine checkup and doctor advised her for fasting lipid profile. Found her cholesterols levels were high and she started on medication tab atorvastatin 10mg In 2010 her husband was diagnosed with cad which worried her so much and took lot of stress but eventually came out of it believing in god. Marital life was good and they haven’t had age difference issues in their life. Her husband has anger outbursts occasionally and small quarrels on differences for example she likes to have fast food but he likes to stay healthy etc. she is very much interested to do a job but her husband had different views on it and doesn’t like girls stepping out of home and hence she remained as house wife took care of household chores and looked after family. In 2000 she had pain abdomen was diagnosed with cholelithiasis and cholecystectomy was done. In 2021 she lost her mother due to natural age related causes. But since it was covid time she wasn’t allowed to go near the body or
Read more