General Medicine
A 65 year old female came with fever, associated with chills
22 August,2022
E LOG GENERAL MEDICINE
Hi, I am Pindi Gayatri , 3rd Sem Medical Student.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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
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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 a diagnosis and treatment plan
CHIEF COMPLAINTS
A 65 year old female came with the complaints of high grade fever associated with chills and rigors since 1 week.
Weakness ,drowsiness-since 4 days
Difficulty in walking and bilateral lower limb weakness since 3 days.
Decreased food intake and missed OHA'S since 2 days.
Passage of urine and stools in clothes due to weakness in both lower limbs since 2 days.
She is a house wife by occupation and staying alone since death of her husband 5 years.
She is apparently asymptomatic 20 years back
She is on medication for hyperthyroidism since 20 years.
Due to decreased appetite went to local hospital and diagnosed as type 2 diabetes mellitus. Since then she was on OHA'S.
HISTORY OF PRESENT ILLNESS
She came with the complaints of high grade fever associated with chills and rigors since 1 week.
Difficulty in walking and bilateral lower limb weakness since 3 days.
Decreased food intake and missed OHA'S since 2 days.
Passage of urine and stools in clothes due to weakness in both lower limbs since 2 days.
She was admitted In the hospital on 16,Aug,2022.
HISTORY OF PAST ILLNESS
It is a known case of Hyperthyroidism, since 20 years and is on neocarbimazole 5mg
It is a known case of Diabetes mellitus, since 10 years and is on Oral hypoglycemic agents.
ASSOCIATED DISEASES
It is not associated with asthma,hypertension, CAD,epilepsy etc
PERSONAL HISTORY
Married
Occupation-house wife
Diet-mixed diet
Appetite-lost
Sleep -adequate
Bowels-regular
Micturition-normal
No known allergies
Habits/addictions -regular alcohol intake
No chewing of betel leaves and nuts
FAMILY HISTORY
Not significant
TREATMENT/DRUG HISTORY
Hyperthyroidism-20 years on neocarbimazole 5 mg po OD
Diabetes-10 years on OHA'S
No hypertension
No CAD
No asthma
No tuberculosis
No antibiotics
No hormones
No blood transfusion
No surgeries
IMMUNIZATION STATUS
Up to mark
GENERAL EXAMINATION
Patient is coherent,conscious,cooperative,
well oriented to time,place and person
She is thin built and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers/toes
No lymphadenopathy
No edema of feet
No dehydration
VITALS
Temperature-98.6 F
Pulse rate-82 beats/min
Respiratory rate-16 times/min
Blood pressure-12/80 mmHg( left arm)
Spo2-98%at room air
GRBS-102 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 Cardiac sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Normal vesicular breath sounds heard
No dyspnea
No wheezing
ABDOMEN
Shape-scaphoid
No tenderness
No palpable masses
No hernial orifices
No free fluid
No bruits
No bowel sounds heard
Non palpable spleen and liver
CNS
Level of consciosness-conscious /alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Cranial nerves,motor system, sensory system, glassgow scale -intact
Reflexes
Biceps triceps supinator knee ankle
Right + + + + +
Left + + + + +
Cerebral signs
Finger nose In-coordination:yes
Knee heel In-coordination:yes
INVESTIGATIONS
ECG
Uncontrolled Diabetes mellitus type 2, secondary to UTI with AKI(resolved)with PAH
Right lower lobe consolidation
PROVISIONAL DIAGNOSIS
Diabetes keto acidosis
