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 

Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE ASSIGNMENT (JULY 2021)

  Name - A. Sri Sai Tarun Roll no - 03 BELOW IS THE LINK TO THE QUESTIONS ASKED TO US : http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1 QUESTION 1 -Below is the link of the student assignment for which I am sharing my peer review . https://shruthiarukonda02.blogspot.com/2021/07/shruthi-arukonda-02.html?m=1 Reviews to all the Questions answered :- 1) The reviews for the cases selected are well described. A detailed pinpoint review has been given to each particular case selected, which is helpful in easy analysis. Even though the peer reviews giving are short they are well described. There is even more possibility for more case depicting points which can be selectively described. 2) Every investigation and detailed history has been correctly described in order. The case of TMJ is depicted in the form of log which has each and every detail of the case. 3&4) The peer review is written on acute kidney injury on chronic kidney disease. A g
Read more

03 Sai Tarun

Image
Diagnosis - viral pyrexia (dengue NS1 positive) UNIT 5ADMISSION: Chief complaints A 14year old male resident of chanduru came in to casualty with chief complaints of  fever since 4 days. C/o cough since 4days Presenting illness Patient was apparently asymptomatic 4 days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and body pains. C/O cough since 4 days which is associated with sputum .  Patient has  h/o  1episode of vomiting 2days back which is non bilious,non projectile. No h/o pedal oedema,decreased urine output,sob,palpitations. No h/o chest pain,abdominal pain PAST HISTORY : Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy. PERSONAL HISTORY: Patient has mixed diet with normal appetite and adequate sleep.  he has normal bowel movements and bladder filling.  No addictions.  FAMILY HISTORY No significant family history or allergic history.  GENERAL EXAMNATION: Patient is c/c/c with moderate built and moderate nourishment
Read more

Meningitis and CAD 03 A SAI TARUN

Image
    GENERAL MEDICNE CASE  12-07-2021 Welcome and greetings to every one who are visiting my blog. This is A Sai Tarun of 3rd sem.  Introduction A 45 year old male is chronic alcoholic since 20 years carpenter by occupation was brought to causality in a state of altered sensorium since 1 day. CHIEF COMPLAINTS •Difficulty in walking & decreased appetite since 15 days. •Constipation since 5 days. •Fever and pedal edema since 3 days •Vomiting since 2 days. HISTORY OF PRESENT ILLNESS •Patient was apparently asymptomatic 6 months. Back until he had b/l pedal edema.he has diagnosed with hypothyroidism. •Patient had difficulty in walking and decreased appetite since then. •H/o constipation since 5 days. •Fever - low grade , intermittent , releived with treatment since 3 days. •B/l pedal edema - pitting , extending upto knees since 3 days. •Vomiting - non bilious , non projectile , associated with food particles since 2 days. •Altered sensorium since 1 day. •Not a k/c/o DM/HTN/Asthma/Epilep
Read more