General medicine case 3

 A 74 year old female with fever 

September 20,2021

This is an online e log book to discuss our patient de-identified health data shared after taking his /her/ guardians signed 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.

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, investigation and come up with diagnosis and treatment plan.

A 74 year old female patient came with complaints of fever since 4 days ,generalised weakness since 4 days.

SOB on exertion since 3 days, which progressed to SOB on rest.

There is a history of 2 episodes of vomiting 1 day ago.

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 days ago, complaints of fever , high-grade, intermittent,not associated with chills and rigors.

Associated with generalised weakness,two episodes vomitings , subsided on its own .

SOB on exertion then progressed to SOB on rest since morning.

There is a history of pericardial effusion 1 year ago , diagnosed on medication for 6 months.

No history of orthopnea, pnd 

No pain abdomen , loose stools.

PAST HISTORY : 

History of DM since 3 years.

History of hypothyroidism since 10 years on regular medication.

PERSONAL HISTORY :

Diet : Mixed 

Appetite : normal 

Bowel, Bladder : regular 

No addictions 

GENERAL EXAMINATION : 

Patient is conscious coherent and cooperative.

Pallor present 

No icterus , cyanosis , clubbing , lymphadenopathy , edema .

Vitals : 

Pulse rate - 86 bpm 

Blood pressure - 100/70 mm/hg.

Respiratory rate - 24 cpm.

Sp02 - 95%

Grbs - 146 mg/dl 

SYSTEMIC EXAMINATION : 

CVS -

S1,S2 Positive 

RESPIRATORY SYSTEM-

Crepts Positive

Nvbs 

P/a : 

Soft , non  tender

 Non palpable mass 

CNS : 

Intact 

PROVISIONAL DIAGNOSIS : 

LEPTOSPIRA WITH RENAL AKI WITH UREMIC ENCEPHALOPATHY WITH HEPATIC ENCEPHALOPATHY GRADE 1 ( RESOLVED).

With DM -2 ,HTN,HYPOTHYROIDISM 

INVESTIGATIONS : 

Platelets at the time of admission : 20,000/cu.mm

Dengue NS 1, IgG, IgM - negative 

CRUSTING OF LIPS : 

PICTURES AFTER TREATMENT : 

CHEST  X RAY :

REPEATED X RAY ON 17/09/2021

ECG : 

2D ECHO :

PERIPHERAL SMEAR : 

TREATMENT : 

INJ. PAN D 40 mg IV/OD 

INJ. ZOFER 4 mg/BD 

TAB. PCM 650mg PO/TID 

NEB BEUDICORT (12thhrly)

INJ DOXY 100 mg PO/BD 

INJ. CEFTRIAXONE 1 gm/IV/BD 

INJ . FALCIGO 120 mg IV /STAT