General medicine case 20-06-22



 GENERAL MEDICINE CASE (20-06-22)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 5th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 19/06/22

Introduction

-55 yr old female Patient came to OPD with chief complaints of fever,chills,vomitings and burning sensation of both feet

HISTORY OF PRESENT ILLNESS

- c/o fever with chills on and off since 3days
- 3 episodes of vomitings since 3days
-c/o black coloured stolls and burning micturition and back pain

HISTORY OF PAST ILLNESS 


K/c/o DM since 1 year.
Not a k/c/o TB,asthama,CAD,HTN,epilepsy.

PERSONAL HISTORY

•Mixed diet

  Appetite Normal

•Sleep adequate

•Bowel and Bladder movements regular.

TREATMENT HISTORY 

 • Not k/c/o HT, CAD , asthma, TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

- k/c/o DM

FAMILY HISTORY 

• Not significant.


GENERAL EXAMINATION

VITALS
Temp:103.8 F
PR: 118bpm
BP:  150/90 mmhg
RR: 20 cycles/min
Spo2: 97%
GRBS: 226 mg%

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - obese

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.


INVESTIGATIONS 



























PROVISIONAL DIAGNOSIS

- Viral pyrexia with thrombocytopenia

TREATMENT: 
Conservative
1) TAB . DOXYCYCLINE 100mg PO/BD 
2) IV fluids NS RL 100ml/hr 
3) INJ PAN 40mg IV/BD
4) TAB DOLO 650mg QID
5) TAB NITROFURANTOIN 100mg PO/BD 
6) SYRUP CITRALKA 
7) GRBS MONITORING 6th hrly
8)INJ HAI SC TID 
9) INJ FALCIPO 120mg Iv 

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