43 M WITH FEVER SINCE 1 DAY
G MEGHANAINTERN , ROLL.NO 51" This is 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 patients 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 comment box is welcome."" 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 "
43 YR OLD MALE WITH FEVER SINCE 1 DAYPatient came to casuality with
Chief complaints of :
- cold and headache since 2 days- fever since 1 dayHistory of present illness :- Patient was apparently asymptomatic 2 days back , he then developed cold , associated with nasal blockage and burning sensation in nose , and headache , throbbing type in forehead region .- H /O fever since 1 day , high grade , continuous , associated with chills and rigors , not relieved by taking medication , no aggravating factors .H/O pain in right flank region since 1 yrNo H/O nausea , vomitings , loose stools , pain abdomen , chest pain , SOB ,cough palpitations , burning micturitionPast history :N/k/c/O HTN , DM , Asthma , TB, Epilepsy, CADPersonal History :Diet - mixedAppetite reducedSleep - adequateBowel and bladder : normalAddictions: occasionally drinks alcoholFamily history : not significantGeneral examination :Patient was conscious , coherent and cooperative , he was examined in a well lit room after having taken his consent
- VITALS :- Temperature -101.9 F
- Pulse rate - 122 bpm
- Respiratory rate - 20 cpm
- BP -130/80 mm of Hg
- SpO2 - 98 % at RA
- No signs of pallor , icterus , clubbing , cyanosis , lymphadenopathy or oedema
SYSTEMIC EXAMINATION :-
CVS :- S1, S2 heard
No thrills or murmurs noted
Respiratory system :- BAE +
-Normals vesicular breath sounds heard
-Trachea is central in position
-No wheezing or dyspnoea present
Per abdominal examination :-
- Soft , non tender , no evidence of organomegaly
- Bowel sounds heard
CNS examination :-
Reflexes :
MOTOR-: normal tone and power
reflexes:
RT LT
Biceps ++ ++
Triceps ++ ++
Supinator ++. ++
Knee ++ ++
Ankle ++ ++
FEVER CHART :
PATIENT'S CLINICAL IMAGES :
Oral cavity examination:
Sinus tenderness examination
Tenderness in frontal sinus
Investigations :
ECG
Chest X Ray PA view
X ray PNS
Cue :
PROVISIONAL DIAGNOSIS : VIRAL PYREXIA UNDER EVALUATION ( SECONDARY TO URTI )
TREATMENT : :
1) IVF 1 UNIT NS,RL,- @75 ml/hr.
2) Inj pantop 40 mg IV OD
3) INJ . NEOMOL 1 GM IV SOS ( IF TEMP > 101 F )
4) INJ ZOFER 4 MG IV SOS
5 ) TAB DOLO 650 MG PO / TID
6 ) TAB LEVICITRIZINE 10 MG PO / BD
7 ) MONITOR VITALS , INFORM SOS
9/2.2023 :
no fever spikes
headache present
passed stools yesterday
ON EXN , Pt is conscious , coherent , cooperative
- VITALS :- Temperature -100 F
- Pulse rate - 122 bpm
- Respiratory rate - 20 cpm
- BP -130/80 mm of Hg
- SpO2 - 98 % at RA
- No signs of pallor , icterus , clubbing , cyanosis , lymphadenopathy or oedema
SYSTEMIC EXAMINATION :-
CVS :- S1, S2 heard
No thrills or murmurs noted
Respiratory system :- BAE +
-Normals vesicular breath sounds heard
-Trachea is central in position
-No wheezing or dyspnoea present
Per abdominal examination :-
- Soft , non tender , no evidence of organomegaly
- Bowel sounds heard
CNS examination :-NAD
FEVER CHART :
PROVISIONAL DIAGNOSIS : VIRAL PYREXIA UNDER EVALUATION ( SECONDARY TO URTI )
TREATMENT :
) IVF 1 UNIT NS,RL,- @75 ml/hr.
Inj pantop 40 mg IV OD
INJ . NEOMOL 1 GM IV SOS ( IF TEMP > 101 F )
) TAB DOLO 650 MG PO / TID
TAB LEVOCITRIZINE 10 MG PO / BD
MONITOR VITALS , INFORM SOS
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