Medicine case discussion

  General medicine case 

HELLO GUYS, 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 evidence based input

I've 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.

Chief complaints:-

A 38 year old female came to casuality with chief complaints of fever and vomitings since 3 days.

History of present illness:-

Patient was apparently asymptomatic  3 days back then she developed fever which is of low grade and associated with chills and rigors and are relived on medication.

Vomting since 3days  of 2episodes daily which was non-bilious and no projectile , containing food particles. History of cold and cough (non productive) were present since 3 days.

No complaint of ‘pedal oedema ,decreased urine output and abdominal distension’.

No complaint of chest pain , palpitations and sob.

History of past illness:-

N/k/c/o HTN, DM, TB, Asthma, CVA, CAD, Epilepsy.

Personal history:-

Marital status:- married

Appetite:- lost

Diet:- mixed

Bowels:- regular

Micturition:- normal

No known allergies.

Family history:- not significant.

Physical examination:-

General examination:-

Patient is c/c/c with moderate build and moderate nourishment 

Pallor:- no

Icterus:- no

Cyanosis:-no

Lymphadenopathy:- no

Malnutrition:-no

Dehydration:-no

Clubbing:- no

Vitals:-

Temperature:- Afebrile

Pulse rate:- 90 bpm

Respiration:-22 cpm

Bp:- 70/50 mmhg

Spo2:- 98%

GRBS:-140 mg/dl

Systemic examination:-

CVS :-s1 and s2 heard,No murmurs.

Rs:-BAE+,NVBS

P/A:-soft and non-tender.

CNS:-No focal deformities.

INVESTIGATIONS:-

Hemogram:-

LFT:-

RFT:-

Serology:- negative

CXR:-

ECG:-

Fever chart:-

Diagnosis:- viral pyrexia with acute gastritis

Treatment given:-

INJ ZOFER 4 mg IV / TID   1-1-1

IVF NS

        RL   @ 100 ml /hr

INJ PAN 40mg IV OD   1-X-X

INJ OPTINEURON 1 amp IN 100 ml NS IV /OD  (OVER 30 mins)    1-X-X

SYP ASCORIL D  10 ml / TID 

10ml  -  10ml  -10ml

ORS

Day 2 SOAP NOTES :-

S-

No fever,cold, vomitings

c/o cough

No fresh complaints

O-

Bp-110/80mmhg

Pr- 86bpm

Cvs:s1s2heard

Rs: BAE+

P/A: soft

A-

Viral pyrexia with acute gastritis

Hb:11gm/dl

Tc:3600

Platelets:1.51

Smear: normocytic normochromic

P-

Inj.Zofer 4mg iv/sos

Inj.PAN 40mg/iv/od

Ivf NS,RL @50ml/hr

Inj.OPTINEURON 1amp in100ml ns/iv/od

Syp.ASCORIL-D 10ml/tid

ORS

Patient was relieved symptomatically and her vomtings was subsided.She had a small daughter , and wanted to take care of her.so, she wanted to go home today(10/10/21). She was discharged at request.