58 year old male with fever

-

 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 patients clinical problems with collective current based inputs.


 CHIEF COMPLAINTS

58 year old male Pt came with the chief complaints of 

fever since 8 days

HOPI 

Pt was apparently asymptomatic 8 days back then had fever which was high grade associated with chills and rigors more during night time associated with cold cough, burning micturition, body pains, nausea, headache.

 No history of vomitings , loose stools, hematuria

PAST HISTORY 

K/C/O ASTHMA since 10 years( used medication for it but now not using)

N/K/C/O HTN , DM, TB, EPILEPSY, CAD

DAILY ROUTINE

wakes up at 5:00 does his daily routines and goes to farm and takes breakfast at 9:00 am and goes to work and takes lunch at 1: 00 pm and goes to work and returns home by 7: 00 and watches TV for some time and takes dinner by 9:00 pm and goes to bed by 10:00 

FAMILY HISTORY

His mother( expired 2 yrs ago)has htn and dm since 10 years

PERSONAL HISTORY 

Diet - mixed

Appetite- decreased

Bowel and bladder movements-regular

Sleep-adequate

Habits-used to consume alcohol 18 years back then he stopped consuming it and use to take 1 pack of cigars 5 years back but since 5 years he is taking 1 or 2 cigars per day


GENERAL EXAMINATION

Patient is conscious coherent cooperative, well oriented to time place person

moderately built and moderately nourished 

 Pallor-absent 

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent






VITALS

BP- 110/80

PR-84

RR-24

TEMP- Afebrile 

SYSTEMIC EXAMINATION

CVS- S1 S2+

RS- BAE+

P/A- soft, non tender

CNS- Intact

INVESTIGATIONS

DAY-1











DAY -2






PROVISIONAL DIAGNOSIS 

Dengue NS1 positive


TREATMENT

1. IV fluids NS, RL @75ml/hr

2. INJ optineuron in 100ml NS IV OD over 30mins

3. INJ Neomal 1gm IV if Temp >101

4. Tab PAN 40mg PO OD

5.Tab hifenac MR PO OD



Comments

Post a Comment

Popular posts from this blog

Online blended Medicine assignment (may)

-
Image
  I have been given  the following cases to solve in an attempt to understand the topic of 'Patients clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations anddiagnosis and come up with treatment plan      This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers  to Medicine assignment based on comprehension of the cases PULMONOLOGY CASE 55 year old female with shortness of breath, pedal edema and facial puffiness https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Questions 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem ?   ans) Evolution of sympt...
Read more

50 YR OLD FEMALE WITH FEVER AND MALAISE

-
Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan. Following is the view of my case... CASE     A 50 year old female came to OPD on 5th of may with chief complaints of         ▪  FEVER since 5 days         ▪   MALAISE  since 5 days HISTORY OF PRESENTING ILLNESS    ...
Read more

70 year old male with fever and weakness

-
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 patients clinical problems with collective current based inputs.  70 year old male with  1)fever since 15 days 2)generalised weakness and body pains  in bilateral lower limbs since 10  days HOPI Pt was apparently asymptomatic 15 days back then had fever which high grade more during night time associated with chills and rigors it is intermittent not associated with cold , cough, vomitings , loose motions, abdominal pain, burning micturition , no h/o rash, hematuria, bleeding from gums For which he was taken to local rmp and  got treated for the same and diagnosed typhoid fever and reports from outside showing platelets of 85,000 Then he had generalised body wea...
Read more