60 Year Female with fever, generalised weakness

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"


I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.


CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Presenting complaints:
Patient came with the chief complaints of fever since 5 days
Weakness since yesterday
HOPI:
Patient was apparently asymptomatic 5 days back then she had fever high grade continuous not associated with chills and rigor
Generalised weakness since yesterday
No nausea, vomitings, abdominal pain.
No loose stools,cough,cold

Past history:
K/C/o diabetes mellitus type 2 since 10 years using glimiperide 2mg Metformin 500mg
N/K/C/o hypertension, asthma,TB,CVA,CAD, Epilepsy

Personal history:
Appetite normal
Sleep adequate
Bowels regular
Micturition normal

General physical examination
Patient is conscious coherent and cooperative
PR 80 bpm
BP 110/70 mm hg
RR 20 cpm
GRBS 520 mg/DL
Temperature 99.4F

Pallor present
No icterus, cyanosis, clubbing, lymphadenopathy, Edema

Systemic examination
CVS -S1S2 present no murmurs heard
RS -bilateral air entry present, NVBS
P/A- soft ,non tender
CNS-NFND HMI


PROVISIONAL DIAGNOSIS
Dengue fever IG M positive
Bilateral pleural effusion
Diabetes acidosis (Resolved)/ AKI on CKD
Anemia of chronic disease
K/C/o diabetes mellitus type 2 since 10 years

Treatment
Inj Erythropoietin SC twice weekly
Inj human actrapid insulin SC/tid
Tab MVT  po/od
Tab shelcal po/od
Tab orofer po/od

Comments

Post a Comment

Popular posts from this blog

A 17 years old female with recurrent attacks of seizures.

Image
This is an 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 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. A 17 year female who is resident of Nakrekal came to causality yesterday evening (1 Dec 2022) with the complaints of  Involuntary movements of both upper limbs and lower limb since 12 pm. HOPI: She was apparently asympt...
Read more

A 29 year male with pain abdomen and loose stools.

Image
This is an 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. 29 yr old male patient resident of chityala who is Court employer by occupation came with the chief complaints of loose stools and  pain abdomen since yesterday evening  HOPI ...
Read more

46 Y F with headache associated with neck pain 20 days

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box" I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan. CONSENT AND DE-IDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall...
Read more