A 65 YEAR OLD FEMALE CAME WITH FEVER SINCE 5 DAYS.

 This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

A 65 year old female came to OPD with -

CHIEF COMPLAINTS-

fever since 4 days.

HOPI-

patient was apparently asymptomatic 5 days back then she developed fever , which is high grade associated with chills and rigor, continuous type, no diurnal variation, associated with vomitings, cold, cough, loss of appetite, generalised body pains.

H/o vomitings since 5 days , sudden in onset, food as content, non bilious, non projectile, non blood stained, 4 to 5 episodes.

H/o cough since 5 days , which is productive whitish sputum thick consistency.

H/o chest pain left sided associated with SOB grade - 2 according to mMRC .

H/o right hypochondriac abdominal pain since 5 days.

No H/o loose stools, burning micturition.

PAST HISTORY-

K/C/O HTN since 2 years and is on medication (unknown)

Not k/c/o DM, TB, asthma, epilepsy, thyroid disorders.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements- regular 

No known allergies 

Addictions-  used to consume pan one or twice daily but stopped from past 4 months.

FAMILY HISTORY- not significant 

GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

Vitals -

BP- 130/80 mmHg

PR- 92 bpm

RR- 18 cpm

TEMP- 98.2 F

PRESENCE OF PALLOR.

NO SIGNS ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.

SYSTEMIC EXAMINATION-

1) CVS- S1, S2 heard, no murmurs.

2) RS- BAE present, NVBS 

3) PER ABDOMEN- diffuse tenderness 

 no organomegaly 

4) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs

INVESTIGATIONS-

CHEST X-RAY-

ECG-

ULTRASOUND-

PROVISIONAL DIAGNOSIS- 

PYREXIA UNDER EVALUATION WITH LEFT LOWER ZONE COLLAPSE.

PRE RENAL ACUTE KIDNEY INJURY.

HYPOKALEMIA SECONDARY TO GE , KNOWN CASE OF HTN SINCE 2 YEARS.

TREATMENT-

1. INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/OD

3. IV. FLUIDS - 2NS @ 75ML/HR

                           - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5. TAB. DOLO 650MG PO/TID

6.  SYP. ASCORIL-LS 15ML/PO/TID.