GENERAL MEDICINE LONG CASE DISCUSSION
55 year old female with history of fever and headache
June 12 ,2022
Long case
Name - Pailla.Manasa
Hall ticket number - 1701006132
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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 diagnosis and treatment plan.
Case:-
55 year old female home maker came to the OPD with cheif complaints of:-
*Fever since 4days
*Headache since 4days
*Neck stiffness since 4days
History of presenting illness:-
Patient was apparently asymptomatic 4days back then she developed fever which was insidious in onset , continuous type , not associated with chills and rigor and relieved on medication.
Patient also complaints of diffuse headache which was throbbing type present throughout the day with no aggravating factors and relieved on medication.
There was a one episode of vomiting which was no projectile, non bilious ,food as content
She also had Neck stiffness associated with puffiness of face and generalized body pains.
No history photophobia , seizures and
Giddiness.
Past history:-
No history of similar complaints in the past.
Not a known case of Diabetes,Hypertension, TB, Asthma, Epilepsy.
Personal history:-
Diet - Mixed
Appetite- Normal
Bowel and bladder - Regular
Sleep - Adequate
No addictions
No drug and food allergies.
Family history
Not Significant
General Examination
Patient was conscious , coherent and co-operative examined under well light and adequate ventilation after taking consent
Moderately built & Moderately nourished
No signs of pallor , icterus ,clubbing , cyanosis, lymphadenopathy and generalized edema.
Vitals
On 9/6/22
Temperature: 99F
B.p: 130/80mmHg
Resp.rate: 18cpm
Pulse rate: 98bpm
Spo2:- 98%
On 10/6/22
Temperature: 99.3F
B.p: 120/80mmHg
Resp.rate: 18cpm
Pulse rate: 78bpm
Spo2:- 99%
On 11/6/22
Temperature: 97.8F
B.p: 110/70mmHg
Resp.rate: 22cpm
Pulse rate: 76bpm
Spo2:- 98%
On 12/6/22
Temperature: afebrile
B.p: 130/90mmHg
Resp.rate: 22cpm
Pulse rate: 74bpm
Spo2:- 98%
Systemic Examination
1)Central Nervous system:-
Higher mental functions
* Level of consciousness - Alert
*speech - Normal
*Meningeal signs:-
Kernigs sign - positive
Neck stiffness- present
Brudzinski sign- positive
*Cranial Nerves Examination - normal
* Motor system
Muscle bulk
Right left
Upper limbs normal normal
Lower limbs normal normal
Muscle tone
Right left
Upper limbs normal normal
Lower limbs normal normal
Muscle power
Right left
Upper limbs
Biceps. 5/5 5/5
Triceps. 5/5 5/5
Supinator. 5/5 5/5
Lower limbs 5/5 5/5
* Sensory system -normal( pain,temperature,
Touch, vibration, pressure) all are well appreciated
* Reflexes
Superficial and deep reflexes are normal
*Gait - Normal
2) Respiratory system
Inspection:-
Shape - elliptical
Bilaterally symmetrical
Movements of chest- Equal on both the sides
Position of trachea - central
No visible scars and pulsations
Palpation:-
Trachea -central
Expansion of chest - Equal on both sides
Tactile Vocal fremitus - Normal
Percussion:-
Resonant on all areas bilaterally
Auscultation:-
Bilateral air entry present
Normal vesicular breath sounds
No added sounds
3) Cardiovascular system
Inspection:-
Shape of chest -elliptical
No per cordial bulging
No visible pulsations and scars
JVP- not raised
Palpation:-
Apical impulse was felt at 5th intercostal space 1cm medial to mid claviculae line.
Auscultation:-
S1,S2 heard , no murmurs.
4) Per Abdomen Examination
Inspection:-
Shape - scaphoid
Umblicus - inverted
All quadrants moving equally with respiration.
No scars, sinuses , visible pulsations and engorged veins
Hernial orifices - free
Palpation:-
Soft, non tender
No hepatomegaly and splenomegaly
Percussion:-
Tympanic note heard
Auscultation:-
Normal bowel sounds heard.
Provisional Diagnosis
Meningoencephalitis/
Dengue Encephalitis with denovo detected type 2 DM.
Investigations
Complete blood picture
9.6.22 & 11.6.22
ABG
Complete urine examination
Liver function tests
Renal function tests
Blood sugar
2D echo
MRI
ECG
Chest xray
Skull xray
CSF Analysis:-
Sugar -81
Protein-12.6
Chloride-113
Treatment
On 9/6/22
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
Syrup cremaffin
On 10/6/22
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
Syrup cremaffin plus
On 11/6/22
IVF @100ml/hr
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
inj.paracetamol 1gm iv sos
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
Ointment Diclofenac
Tab.metformin 500mg OD
Inj.PAN 40mg iv
Tab.Naprozeen 250mg TID
Syrup cremaffin 30ml po HS
On 12/6/22
IVF @75ml/hr
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Tab.paracetamol 650mg TID
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
INj.paracetamol 1gm iv sos
Ointment Diclofenac
Tab.metformin 500mg OD
Inj.PAN 40mg iv
Tab.Naprozeen 250mg TID
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