A 40 year old with fever and vomitings




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 evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. 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 evident based input

K.Phani Keerthana 
Roll no 72
 
A 40 year old male agriculture labourer by occupation resident of chitiyal came to opd with chief complaints of 
Fever since 2 days
Vomiting since 1 day
 
HOPI- Patient was apparently asymptomatic 2 days back then he developed fever with chills and rigor sudden in onset and continuous 
Not relived on medication 

H/o vomiting associated with nausea since yesterday 1 episode.food particals as content non bilious and non projectile type
 
No h/o burning micturition
No h/o rash
No H/o abdominal pain and distension 
No h/o diarrhoea 
No h/o neck rigidity
No h/o night sweats
No h/o weight loss
He visited local hospital in chitiyal on the day of fever where the medication were given and the fever didn’t relieve.

Past history-
Not a known case of DM HTN thyroid epilepsy 

Family history-
Not significant 
 
Personal history-
 Diet- Mixed
Appetite- Normal
Bowel and bladder-regular 
Sleep- adequate 
Addictions-consumes alcohol and toddy occasionally 

General examination- patient is conscious coherent cooperative well oriented to time place and person moderately built and nourished 
Patients was examined in well lit room and consent was taken 
 
Vitals 
Pulse rate- 65bpm
B.P - 110/80
R.R 20/ min
SpO2-92%

                    



       
 
No signs of 
Pallor icterus 
Cyanosis 
Clubbing 
Lymphadenopathy 
Edema

Systemic examination- 
 Per abdomen- 
On inspection shape-normal
Umbilicus central 
No visible scars 
No engorged veins
All quadrants equally move with respiration 
No visible pulsations




Palpation- All inspectory findings are confirmed 
Soft and non tender
No organomegaly 
No rigidity

Percussion- No fluid thrill 

Auscultation- bowel sounds are heard

Respiratory system- ON inspection trachea, scar on right upper part of chest
   Palpation bilateral symmetrical expansion of chest
Auscultation- normal vesicular breath sounds 

Cvs -
Inspection - No scars or engorged veins
Palpation apex beat felt 
Auscultation- S1 S2 heard No murmers 
  
Cns- patient is consious coherent cooperative well oriented to time place and person.
Cranial nerves - intact
Sensory system- normal
Motor Tone power bulk reflexes are normal in all 4 limbs 

Fever chart- 
  
Provisional diagnosis - Fever under evaluation with thrombocytopenia and hypotension

INVESTIGATIONS- Hemogram
  RBS-  
Blood urea
 
Serum electrolytes 
L 
LFT-  
Dengue NS1 antigen- 
Widal  test  
 
Serum creatinine 
 
ECG-  

 
Treatment- I.V fluids (NS,ringer lactate)
                   Inj.neomol 
                   Tab dolo
                   Plenty of oral fluids
                    Tepid sponging 
                    Inj monocef 
                    Inj.Falcigo 

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP LEARNING AND PROCEDURES PERFORMED

Image
  Anecdotal self reflections on their internship learning with some video  evidence of procedures performed  MY INTERNSHIP:-  Iam posted in medicine posting from 31 st july to 30 sept  Of this  ICU :- (1st august -6 th august)  Learned about VENTILATOR Assisted in 6 intubations  Done CPR TOOK SAMPLES  ABGs were taken by me  ABG sample from brachial artery                          Done procedure’s :- 4 ryles ; 5 foleys catheterisation  Learned how to use bipap machine   NEPHRO :- (7 th august - 12 th  august ) Learned about procedures like central line . Monitored patients in dialysis  Learned about the process of dialysis ; types of dialysis ;  Assisted in 4 central lines  Complications of dialysis  Done CPR.  WARD :-  Monitored patients in the nyt Took samples of FBS ; PLBS; HBA1C ; RFT ; LFT    Done IV canulation  PSYCHIATRY:- 15 August     to 1 st sept  MY PSYCHIATRY :-  I came across a patient , who was diagnosed with DISSOCIATIVE DISORDER. Diagnosis DISSOCIATIVE DISORDER Case Hist
Read more

Evidence based date wise workflow logs collated by the intern with clickable and verifiable link

Image
2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links As of 19/9/23 :-  CASE 1:- PaJR Group  https://chat.whatsapp.com/Jc43jR1klLF7ovLA3oagvU Blog :-  https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html [05/09/23, 8:54:43 AM] ~ Keerthi Madireddi: @919381040824 update soap notes and also draw a graph showing the potassium values and intervention done. [05/09/23, 8:55:52 AM] Keerthana: Ok mam [05/09/23, 9:02:57 AM] ~ Keerthi Madireddi: @919381040824 please make me and hod sir as admin [05/09/23, 9:04:03 AM] ~ Keerthi Madireddi:  ☝🏻 [05/09/23, 9:46:51 AM] Rakesh Biswas Sir Hod Medicine: Mention duration in the title [05/09/23, 10:40:57 AM] Keerthana: Date-5/9/23 Ward-ICU    Bed 5  Unit 6  Date of admission 2/9/23 S -  C/o weakness in both upper and lower limb, C/o slurring of speech since 4 days  O -  On examination  Patient is conscious coherent and cooperative.  No Pallor, Icterus, cyanosis, cl
Read more

Self reflective writing on their medical student career 

Image
  Self reflective writing on their medical student career  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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information. This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome. BLOG LINK :- https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html It was my first Casuality duty day, I came across my 1 st case, A 70 year old was coming in a stretcher  with chief complaints of weakness in both upper limb and lower limb Since 1/2/23 evening  Slurring of speech since 1/2/23 evening. And I have no clue what to do  Then I decided to think what
Read more