47 Y / M CAME TO CASUALTY WITH FEVER, COUGH, LOOSE STOOLS SINCE 3 DAYS

 This is an a 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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


C/O FEVER SINCE 3 DAYS

C/O COUGH SINCE 3DAYS

C/O LOOSE STOOLS SINCE 3 DAYS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK THEN HE HAD FEVER WHICH IDS HIGH GRADE ASSOCIATED WITH CHILLS AND RIGORS CONTINUOUS, RELIVED  BY TAKING MEDICATION

COUGH SINCE 3DAYS ASSOCIATED WITH SPUTUM , YELLOWISH IN COLOR, NON BLOOD STAINED, MUCOID IN CONSISTENCY

C/O LOOSE STOOLS SINCE 3 DAYS YELLOWISH TO RED IN COLOR

NO PEDAL EDEMA

BURNING MICTURATION +

NO ABDOMINAL PAIN

PAST HISTORY:

K/C/O DM II SINCE 4 YEARS ON TAB METFORMIN 500MG PO OD

K/C/O CAD SINCE ON AND OFF  ON

TAB TRIMETAZIDINE MR 35MG,

TAB DYTOR PO OD

TAB TELMA 40MG + METAPROLOLPO OD

TAB ECOSPRIN GOLD 20 PO HS

TAB EPLERENON 25 MG PO OD

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER: INCREASED SINCE 3 DAYS

ADDICTIONS: CIGARETTES 4 PER DAY REGULARLY, STOPPED DRINKING ALCOHOL SINCE 2 YEARS

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:103

BP:100/70 MM HG

PR:86 BPM REGULARLY IRREGULAR

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

GRBS: 113MG%

SPO2: 92 ON ROOM AIR

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

INVESTIGATIONS:

HBsAg-RAPID 17-01-2024 10:49:AM Negative

 

Anti HCV Antibodies - RAPID 17-01-2024 10:49:AM Non Reactive


COMPLETE URINE EXAMINATION (CUE) 17-01-2024 10:49:AM


COLOUR Pale yellow

APPEARANCE Clear


REACTION Acidic


SP.GRAVITY 1.010


ALBUMIN ++


SUGAR Nil


BILE SALTS Nil


BILE PIGMENTS Nil


PUS CELLS 5-6


EPITHELIAL CELLS 2-4


RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil


AMORPHOUS DEPOSITS Absent


OTHERS Nil


WIDAL TEST 17-01-2024 10:49:AM


S.typhi "O" Antibodies No Agglutination seen

 

S.typhi "H" Antibodies No Agglutination seen


S.PARATYPHI "AH" ANTIBODY No Agglutination seen


S.PARATYPHI "BH" ANTIBODY No Agglutination seen


BLOOD UREA 17-01-2024 10:49:AM 25 mg/dl 42-12 mg/dl


SERUM CREATININE 17-01-2024 10:49:AM 1.0 mg/dl 1.3-0.9 mg/dl


SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-01-2024 10:49:AM


SODIUM 139 mEq/L 145-136 mEq/L


POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L


CHLORIDE 105 mEq/L 98-107 mEq/L


CALCIUM IONIZED 1.18 mmol/L mmol/L


POST LUNCH BLOOD SUGAR 17-01-2024 10:50:AM 120 mg/dl 140-0 mg/dl


LIVER FUNCTION TEST (LFT) 17-01-2024 09:26:PM


Total Bilurubin 0.60 mg/dl 1-0 mg/dl


Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl


SGOT(AST) 18 IU/L 35-0 IU/L


SGPT(ALT) 16 IU/L 45-0 IU/L


ALKALINE PHOSPHATE 96 IU/L 128-53 IU/L


TOTAL PROTEINS 6.6 gm/dl 8.3-6.4 gm/dl


ALBUMIN 3.5 gm/dl 5.2-3.5 gm/dl


A/G RATIO 1.16

2D ECHO:

EF 49%

TRIVIAL TR+, NO MR/AR

RWMA +,M CAD HYPOKINETIC, NO AS/MS

MILD LV DYSFUNCTION

NO DIASTOLIC DYSFUNCTION

TREATMENT:

INJ MONOCEF  1GM IV BD

INJ DOXYCYCLINE 100MG IV BD

TAB PCM 650 MG PO SDOS

TAB ECOSPRIN GOLD 75/75/20 PO HS

TAB DYTOR PO OD

TAB TELMA 40MG + METOPROLOL 50 MG PO OD

TAB TRIMETAZIDINE MR 35 MG PO BD

TAB EPLERENONE 25MG PO OD

TAB METFORMIN 500MG  PO OD

SYP GRILLINCTUS 10ML TID

TAB CEPODEM XD 325MG PO BD 

TAB MONTAC LC PO 

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