1601006100
This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed.
I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE DISCUSSION:
A 35year old female farmer by occupation came with complaints of fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.
HOPI:
Patient was apparently asymptomatic 6 months back and then developed b/l small joint pain for which she was treated in private hospital at miryalaguda and now came with complaints of fever which was associated with chills and rigor,evening rise of temperature and with burning micturation,associated with abdominal pain which was diffuse and lower back pain and dry cough.
No cold
No h/o bleeding manifestations, no h/o melena, no h/o rash.
PAST HISTORY:
not a K/C/O DM,HTN,TB,EPILEPSY,ASTHMA.
PERSONAL HISTORY:
She is Married and farmer by occupation.
She consumes
Mixed diet
sleep is adequate
Appetite normal
bowel and bladder movements are regular
no addictions
FAMILY HISTORY: no similar complaints in the family.
DAILY ROUTINE: 6 months back (when pt was normal) she used to getup at 5am and do house chores and then after having her breakfast she used to go for work on farm from 10am to 5pm, she used to have her lunch there itself. After coming back from farm she used to do her chores and sleep by 9pm.
(After getting joint pains) Pt used to get up at 6am and stopped going to farm used to do some house chores and then used to take rest and sleep by 10pm.
CLINICAL IMAGES:
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative and well oriented to time place and person,
Moderately built and moderately nourished.
VITALS:
BP: 100/50mmhg
PR: 78bpm
RR: 20cpm
Temp: 97.6f
GRBS: 102mg/dl - 8am
Spo2: 98%
SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD
PROVISIONAL DIAGNOSIS: Viral pyrexia under evaluation
INVESTIGATIONS:
TREATMENT:
1.IVF 10NS 10RL @ 100ml/hr
2.INJ.PAN 40mg/IV
3.TAB.DOLO 650mg/PO SOS
4.SYRP. CITRALCA 5ml
5. INJ.NEOMOL 1gm/IV/STAT
6.Monitor vitals every 4th hrly
Day 2
S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.
Presently fever +, generalised body pains.
O: pt is conscious, coherent,cooperative.
BP: 100/50mmhg
PR: 78bpm
RR: 20cpm
Temp: 97.6f
GRBS: 102mg/dl - 8am
Spo2: 98%
SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD
A:Viral pyrexia under evaluation
P:
1.IVF 10NS 10RL @ 100ml/hr
2.INJ.PAN 40mg/IV
3.TAB.DOLO 650mg/PO SOS
4.SYRP. CITRALCA 5ml
5. INJ.NEOMOL 1gm/IV/STAT
6.Monitor vitals every 4th hrly
Day 3
S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.
Presently no fever spike , pain abdomen .
O: pt is conscious, coherent,cooperative.
BP: 100/90mmhg
PR: 90bpm
RR: 20cpm
Temp: 96.6f
GRBS: 84mg/dl - 8am
Spo2: 97%
SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD
A:Viral pyrexia under evaluation
P:
1.IVF 10NS 10RL @ 100ml/hr
2.INJ.PAN 40mg/IV
3.TAB.DOLO 650mg/PO/TID
4.SYRP. CITRALCA 5ml
5. INJ.NEOMOL 1gm/IV/STAT
6.Inj.Optineuron 1amp in 100ml @ 50ml/hr
7.Syrp.Potklor 15ml in 100ml water po/TID
8.Tab.Cetrizine 10mg/PO/OD
9.SYRP.CITRALICA 15ml with 1/2 glass water
10. Monitor vitals 4th hrly
Day 4
S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.
Presently fever spike , pain abdomen .
O: pt is conscious, coherent,cooperative.
BP: 110/80mmhg
PR: 88bpm
RR: 28cpm
Temp: 100.7f
GRBS: 102mg/dl - 8am
Spo2: 98%
SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD
A:Viral pyrexia under evaluation
P:
1.IVF 10NS 10RL @ 100ml/hr
2.INJ.PAN 40mg/IV
3.TAB.DOLO 650mg/PO/TID
4.SYRP. CITRALCA 5ml
5. INJ.NEOMOL 1gm/IV/STAT
6.Inj.Optineuron 1amp in 100ml @ 50ml/hr
8.Tab.Cetrizine 10mg/PO/OD
9.SYRP.CITRALICA 15ml with 1/2 glass water
10. Syrp.Potklor 15ml in 100ml water po/TID
