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.
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.
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