Medicine case discussion

 41 YEAR OLD MALE PATIENT WITH HISTORY OF FEVER AND ALTERED SENSORIUM



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Pailla.Manasa,

8th Semester,

Roll no: 102

June 03 2021


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. 


CASE DISCUSSION


Case :-


41year old male resident of Chalakurthy

Presented to the OPD on 01/06/2021 with 

Cheif complaints of 


  • Fever  - since 2days
  • Altered sensorium with irrelevant talk               -  since 1day.


HISTORY OF PRESENTING ILLNESS

 

Patient was apparently asymptomatic  2days back then he developed high grade fever with ear pain following which he went to local RMP and had 2 injections.Since yesterday he had altered sensorium with irrelevant talk.

FEVER

  • High grade fever
  • Insidious in onset
  • Intermittent in nature
  • Duration = 2days
  • Associated with Ear pain
  • No chills & rigor
  • No Aggravating factors
  • Relieved by taking  Antipyretic.


PAST HISTORY


* He is a known case of Diabetes mellitus and Hypertension since 2 years.

* No history of Asthma,Thyroid, Tuberculosis , Epilepsy & CVS problems.

* History of head injury two and half years back was in coma for 20 days followed by abnormal behavior.


DRUG HISTORY


* D.M =  No medications taken.

* HTN = Tab. Telmesartan 40mg OD

                Tab.Clinidipine 5mg OD

*Abnormal behavior 

               Tab.Ecitalopram.


PERSONAL HISTORY


* Diet = Mixed

* Appetite = Normal

* Bowel and Bladder = Regular

* Sleep = Adequate

* No Addictions

* No Drug Allergies


FAMILY HISTORY


* Father had a history of Diabetes       mellitus and Hypertension .


GENERAL EXAMINATION


* Patient was examined in well light and good ventilation room.

*Patient has altered sensorium and not responding to commands.

* Moderately built and Moderately      nourishment.


               No Pallor

               No Icterus

               No Cyanosis

               No Clubbing

               No Bilateral pedal oedema

               No Lymphadenopathy.

         * Mild dehydration present



Vitals at the time of admission 

JUNE 01 2021


Temperature = 100.3 F

Pulse rate = 18 cycles permin

Respiratory rate = 80 beats/min 

Blood pressure = 140/70 mm of Hg

Spo2 = 99% at room air

GRBS = 143 mg/dl.



VITALS ON JUNE 02 2021



     *Temperature = 98.4 F

       Pulse rate = 21 cycles permin

       Respiratory rate = 86 beats permin

       Blood pressure = 110/60 mm of Hg

       Spo2 = 97% at room air

       GRBS = 189mg/dl.


VITAL ON 03.06.2021


Temperature = 97 F

Pulse rate = 97beats permin

Blood pressure = 110/80 mm of Hg

Spo2 = 98 % at room air

GRBS = 167 mg/dl


VITALS ON 04.06.2021


Temperature = Febrile

Pulse rate  = 68 beats Per min

Blood pressure = 120/80 mm of Hg


TPR GRAPHIC SHEET





SYSTEMIC EXAMINATION


* CVS -  S1 , S2 sounds heard

               No murmurs.


* Respiratory system

~Normal vesicular breath sounds heard

~ Bilateral air entry present (BAE+ve)


* Abdomen

           Soft and Tender

           Bowel sounds normal

           No Organomegaly.


* CNS

# Level of consciousness - 

                                    Drowsy1Arousable

# Speech - Incoherent

# No meningeal irritation

# Muscle tone - Normal

# Muscle power -5/5

# Glasgow scale - Altered.


INVESTIGATIONS


Complete Blood Picture (CBP)


* Hemoglobin = 12 gm /dl

* TLC = 25,000

* DLC

            - Neutrophils = 90%

            -Lymphocytes = 04%

            -Eosinophils = 02%

            -Monocytes = 02%

            -Basophils = 00%

* Platelets = Adequate


                     June 02 2021





June 04 2021



HEMOGRAM





LIVER FUNCTION TEST (LFT)


* Total bilirubin -  1.62 mg/d1

* Direct bilirubin - 0.74 mg/dl

* AST (SGOT) - 25 IU/L

* ALT (SGPT) - 12 IU/L

* Alkaline phosphatase - 79 IU/L

* Total proteins -6.5 gm/dl

* Albumin - 3.5 gm/dl

* A/G ratio -1.20




RENAL FUNCTION TEST


* Urea                = 36mg/dl

* Creatinine    = 0.8mg/dl

* Uric acid.      = 4.3mg/dl

* Calcium.       = 9.6 mg/dl

* Phosphorus. = 2.0 mg/dl

* Sodium.         = 136 mEq/L

* Potassium.     = 38 mEq/L

* Chloride.        = 92 mEq/L





BLOOD SUGAR FASTING


June 02 2021




June 04 2021


BACTERIAL AND SENSITIVITY REPORT


June 03 2021



June 04 2021



ECG REPORT




Patient referred to :-


Psychiatry (on June 01 2021)



With cheif complaints of -
 
* Altered sensorium with irrelevant talk since 1day

* History of head injury 21/2 yrs back.

~ Diagnosis :-

ADJUSTMENT PERSONALITY DISORDER.

Treatment 

Inj.Lorazepam 1/2amp /iv sos
Tab.Nexitoplus @ 8:30 pm OD.
.





DVL (on June 04 2021)



With chief complaints of :-

* Vesicular lesions on lips and face
 ( cheek) since 3 days
 
# History of similar complaints in the past.

Diagnosis :-
    
EXTENSIVE HERPES LABIALIS.

Treatment 


CALAMINE LOTION BID ,7days

EUDIC CREAM ( on raw areas ) BID 7days

Tab.Zincovit OD 30 days.


PROVISIONAL DIAGNOSIS


Viral pyrexia, secondary to Adjustment personality disorder with HTN & DM.


TREATMENT HISTORY


JUNE 01 2021


Inj.Pantop 40mg /iv/ OD

Inj.Ceftriaxone 1gm / iv / OD

Inj .Zofer 4mg /iv/ TID

Inj. Thiamine 200mg /iv/TID

Tab. Paracetamol 650mg /po/TID

Tab. Clinidipine 10mg / po / OD

IVF ( N.S & RL )@ UO /50ml per hr


JUNE 02 2021


Inj.Pantop 40mg /iv/ OD

Inj.Ceftriaxone 1gm / iv / OD

Inj .Zofer 4mg /iv/ TID

Inj. Thiamine 200mg /iv/TID

Tab. Paracetamol 650mg /po/TID

Tab. Clinidipine 10mg / po / OD

Inj. NEOMAL 100ml / iv / sos if tem >102F

IVF ( N.S & RL )@ UO /50ml per hr

Inj.Lorazepam 1/2 amp iv/ sos

Tab.NEXITOPLUS @ 8:30pm OD


JUNE 03 2021


Inj.Pantop 40mg /iv/ OD

Inj.Ceftriaxone 1gm / iv / BD

Inj .Zofer 4mg /iv/ TID

Inj. Thiamine 200mg /iv/TID

Tab. Paracetamol 650mg /po/TID

Tab. Clinidipine 10mg / po / OD

Inj. NEOMAL 100ml / iv / sos 

Inj.Lorazepam 1/2 amp iv/ sos

Tab.NEXITOPLUS @ 8:30 pm OD


JUNE 04 2021


Inj.Pantop 40mg /iv/ OD

Inj.Ceftriaxone 1gm / iv / BD

Inj .Zofer 4mg /iv/ TID

Inj. Thiamine 200mg /iv/TID

Tab. Paracetamol 650mg /po/TID

Tab. Clinidipine 10mg / po / OD

Inj. NEOMAL 100ml / iv / sos 

Inj.Lorazepam 1/2 amp iv/ sos

Tab.NEXITOPLUS @ 8:30 pm OD

CALAMINE LOTION BID ,7days

EUDIC CREAM ( on raw areas ) BID 7days

Tab.Zincovit OD 30 days.



I would like to thank Dr.Rakesh Biswas sir for giving me this opportunity and Dr.Sai Charan sir for the guidance.





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