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.
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
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
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
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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