General Medicine
27,August, 2022.
A 38 year old male with fever,loss of appetite, headache and Nausea.
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 38 year old male came to the casuality with the complaints of fever,headache,loss of appetite, Nausea since 5 days on 25th, August.
HISTORY OF PRESENT ILLNESS
He came to the casuality with the complaints of fever since 1 week. Headache since 4 days. Nausea and vomitings 2 days back.
He was apparently normal 5 years back ,then he was in stress as his brother had serious health issue. Following which he developed low grade fever and neck pains ,then diagnosed with hypertension.
Since 1 week had fever with chills ( low grade)associated with headache and neck pains.
No joint pain ,No blurring of vision,No seizures.
He went to the nearby hospital for the reason of fever recently and MRI was done.
HISTORY OF PAST ILLNESS
Known case of hypertension, since 5 years on tablets. T.MET-XL 50 mg
T.TELMA -40mg
T.chlorthalidone -12.5mg
Not a known case of Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.
TREATMENT/DRUG HISTORY
No Diabetes
Hypertension-since 5 years on Telma-40 mg
T. MET-XL- 50mg
T.chlorthalidone- 12.5mg
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No Chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Married
Occupation-labourer
Diet-mixed
Appetite-normal
Bowels-regular
Micturition-abnormal
No known Allergies
Habits/addictions - alcohol-occasional
FAMILY HISTORY
No Diabetes
No Hypertension
No Heart disease
No stroke
No cancers
No tuberculosis
History of Asthma was present(mother).
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITALS
Temperature-98.3°F
Pulse rate-101 bpm
Respiratory rate-20 cpm
Blood pressure-130/90 mmHg(left arm)
SpO2 at room air-100%/at RA litres of 02
GRBS-130 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds
No dyspnea
No wheezing
ABDOMEN
Shape of the abdomen-scaphoid
Tenderness -present in epigastrium
No palpable mass
Normal hernial orifices
No free fluid
No bruits
Non palpable liver
Non Palpable spleen
No Bowel sounds
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Reflexes
Biceps Triceps supinator knee ankle
Right ++ ++ ++ ++ ++
Left ++ ++ ++ ++ ++
Plantars-flexor
Cerebral signs
Finger nose In-coordination:No
Knee heel In-coordination :No
INVESTIGATIONS
On 25th, August
Ultrasound report
On 26th of August
Patient ,38 years old associated with fever since 1 week. ?pyelonephritis
Severe right sided(unilateral)headache.Not subsiding with basic NSAID'S.
FUNDOSCOPY in view of any features of raised ICT.
Prescription for glasses(on 26th, Aug)
Doppler-2D Echo(on 26th,Aug)
ECG
PROVISIONAL DIAGNOSIS
? Pyrexia
?sepsis associated with MODS(2° to bacterial)
?LEPTOSPIROSIS.
