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.
A 53 yr old male patient of daily worker by occupation came to OPD on 18/01/2023.
HuCheif complaint:
The patient came to casualty with a cheif complaint of :
-Fever since 4 days
-Abdominal discomfort and bloating since 4 days
-constipation and no passage of stools since 4 days.
History of present illness:
-Patient was apparently asymptomatic 4 days back, then he developed high grade fever which is intermittent and associated with chills and rigors, headache and constipation.
-He also complains of abdominal discomfort and bloating since 4 days .
-C/o loss of appetite
-H/o burning micturation
-H/o shortness of breath.
-No h/o of vomitings.
The symptoms are relieved by medication and no h/o aggravating factors.
Past history:
There is a history of Diabetes mellitus 2 since 10yrs. Patient is on regular medication of metformin(500mg)+glimipiride(100mg).
There is a history of CAD- PTCA done 4 years back.
Not k/c/o Hypertension, Asthma, epilepsy, CKD,thyroid.
Known alcoholic since 20 years (regular)
Stopped smoking 4 yrs back- 2 packs of cigarette daily before 4 years for continous 25 years.
Personal history:
Diet:mixed
Appetite:loss of appetite
Sleep:Adequate
Micturation:present(burning)
Bowel &bladder movements:Irregular(since 4 days)
Addictions: alcoholic
Family history:
No relevant family history is seen.
Drug history:
No known history of drug allergy
General examination:
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Pitting edema present in lower limbs
Vitals:
Temp- 101°F
BP-140/80MMHG
RR-18CPM
PR- 92BPM.
GRBS-167mg/dl.
Spo2 - 92%
Systemic examination:
ABDOMEN:
Shape: scaphoid
Flanks:free
Umbilicus: central &inverted
no scars,no scratches,
No dilated veins
Movements are normal
No visible pulsations
Cullens sign-negative
Gray turners sign-negative
PALPATION:
no raise of temperature
no tenderness
Kidney and spleen not palpable
no palpable mass
PERCUSSION:
No fluid thrill
No Shifting dullness seen
AUSCULTATION:
bowel sounds heard
No bruit
RESPIRATORY:
INSPECTION:
Chest: symmetrical
Trachea: central
No drooping of shoulders,
no supraclavicular hollowing
no kyphoscoliosis
no use of accessory respiratory muscles
Movement with respiration is symmetrical on both sides
PALPATION:
trachea: central
no intercoastal widening
Whole thorax measurement:34 inches
Hemi Thorax:17 inches
Vocal fremitus -normal
PERCUSSION:
Dullness noted from 5th intercoastal space
AUSCULTATION:
vesicular breath sounds
No added sounds
CVS:
S1&S2 heard
No thrills,no murmurs
CNS:
Concious
Speech:normal
Gait: normal
No signs of neck stiffness
Sensory system :normal
Motor system: normal
Investigations:
ABG:
Urine for ketone bodies:
RBS:
Glycated haemoglobin:
Hemogram:
Impression: Normocytic normochromic blood picture with thrombocytopenia.
RFT & LFT:
2D Echo:
USG:
Impression : right renal calculi and cystitis correlate with CUE.
ECG:
Chest X ray:
Diagnosis:
Viral pyrexia with Thrombocytopenia with
Type 2 Diabetes Mellitus
Treatment:
Inj pan 40mg IV /OD
Inj optineuron 1 amp M100ml NS IV/OD
Inj Thiamine 200 mg M 100ml NS IV/BD
Inj lasix 40mg IV / BD
Tab dolo 650mg
Grbs profile monitoring
Plenty of oral fluids
Monitoring vitals.
Comments
Post a Comment