GENERAL MEDICINE
23/09/2023 62 year female with fever, headache,chest pain
September 22, 2023
Hi, I am Pindi Gayatri, 5th 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 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint:
A 62 year old female resident of farmer by occupation came to OPD with chief complaints of
-Fever since 5 days
-chest pain since 5 days
-headache since 15 days
History of Present Illness:
-Patient was apparently asymptomatic 5 days ago then she had fever which is sudden in onset, intermittent,high grade associated with chills and rigors,relieved with medication.
-Productive cough - white sputum,thick consistency
-Chest pain for past 5 days which was sudden in onset, continuous,dragging type of pain, aggravated by coughing and sleeping no radiating features
-Headache severity increased for past 15 days, insidious in onset ,aggravated while bending .
-Pain was radiating to entire head and neck.
Daily Routine:
Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.
After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past History:
No similar complaints in the past.
Not a k/c/o DM, HTN, CAD, TB, epilepsy.
Surgical history:
ENT surgery 6 years back
Personal History:
- married
- appetite lost
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- addictions: no known addictions
Family History: not significant
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- Temperature: afebrile
- Pulse: 72 beats/min
- RR: 17 cycles/min
- BP: 110/70 mm Hg
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- no wheeze
- dyspnoea present
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
BICEPS TRICEPS SUPINATOR
RIGHT +2 +1 +1
LEFT +2 +1 +1
KNEE ANKLE
RIGHT +1 +1
LEFT +1 +1
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
- Hb :13.6
- PCV: 38.9
- TLC: 7300
- RBC: 4.54
- Platelet count: 2.25
- B.urea: 39
- S.creatinine: 0.8
- S.Na+: 139
- S.k+: 3.6
- S.cl: 102
- T.bilirubin: 0.61
- D.bilirubin: 0.19
- SGPT: 20
- SGOT: 42
- alk.phosphate: 226
- T protein: 7.7
- Albumin: 3.70
- A/G ratio : 0.93
RFT:
- Urea : 39 mg/dl
- Creatinine: 0.8 mg/dl
- Uric acid: 3.3 mg/dl
- Calcium: 10.1 mg/dl
- Phosphorus: 3.9 mg/dl
- Sodium: 139 mEq/L
- Pottasium: 3.6 mEq/L
- Chlorine: 102 mEq/L
LFT:
- Total bilirubin : 0.61 mg/dl
- Direct bilirubin: 0.19 mg/dl
- SGOT: 42 IU/L
- SGPT: 20 IU/L
2D ECHO:
USG:
ECG:
Provisional Diagnosis:
-Pyrexia under evaluation
-Community acquired pneumonia
Treatment:
1.TAB.PCM 650 mg PO/OD
2.TAB.BUSCOPAN PO/OD
3.TAB.PAN 40 mg PO/OD
4.SYRUP.ASCORYL LS PO/TID 15 ml
