February 14, 2023
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Name : B Krishna ( Intern )
Roll Number : 79
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.
51YR OLD FEMALE came with C/O Fever since,SOB and Headache since 1 week
HOPI :
Patient was apparently asymptomatic 1 week ago , then he developed fever which is insidious in onset high grade which is aggravated at night times associated with chills and rigors and relieved by taking medication.
SOB since 1 week, grade 2 relieved by taking rest no orthopnea no PND no chest pain.
Headache since 1 week ,diffuse type more in occipital region.
Abdominal tightness present, burning micturation present(intermittent type),increased urine output.
No Nausea Vomitings loose stools
No photophobia or phono-phobia
No cold or cough
H/O bilateral hydronephrosis 6 months back
PAST HISTORY:
K/C/O HTN since 10 years on Telma-H (40mg+12.5mg)
N/K/C/O DM TB epilepsy CVA CAD asthama
Appetite -decreased since 1 week
Diet - Mixed
Sleep - adequate
Bladder movements - regular
Bowel movements - regular
Addictions - nil
GENERAL EXAMINATION:
Patient is conscious,coherent , cooperative
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - absent
Temp : 101 F
BP : 80/60mmHg
PR : 111bpm
RR : 20cpm
SpO2 : 96% On RA
GRBS : 155mg/dl
Systemic Examination:
CVS : S1 S2 + ,No murmurs .
CNS : HMF intact , NAD
P/A : Soft ,Distended ,Non tender
SYSTEMIC EXAMINATION:
ON INSPECTION:
Shape of the chest is elliptical
Respiratory rate is 28 bpm and rythm is regular
Type of respiration is Thoraco-abdominal type
Right supra scapular hallowing is present
Movements are B/L symmetrical
There is no use of any accessory muscles
Trial sign is negative
Apex beat cannot be assessed
No swelling or dilated veins present
No rectractions present
PALPATION :
all inspectory findings confirmed
No rise of temperature
Tenderness over the 7th ICS @ right side
Trial sign is negative
Transverse diameter is 20cm and AP diameter is 23 cm
Tactile fremitus equal on both sides
Expansion of chest on inspiration is 98 cm and on expiration is 96 cm
Apex impulse cannot be assessed
PERCUSSION :
Resonant over all areas
Liver dullness- liver span could not be assessed
Cardiac dullness-lateral border could not be assessed
Medial border lateral to the border of sternum at 3rd 4th and 5th ICS
Traubes space- resonant
Kronigs isthumus- B/L resonant
Tidal percussion-normal
AUSCULTATION:
Clear in supraclavicular infraclavicular mammary and infra mammary areas
Fine crepts in left infra axillary and B/L infra scapular areas
DIAGNOSIS:
Pyrexia secondary to ? Lower respiratory tract infection
Iv fluids NS and RL @150 ml/hr
Inj.Pan 40 mg iv/od
Inj.neomol 1gm iv/sos (if temp >101 F)
Inj.agumentin 1.2gm iv/bd
Tab.PCM 650mg po/qid
Inj.Zofer 4mg iv/od
Tab.Telma-H po/od
Bp pr rr temp monitoring 4th hourly
17/2/23
51 year old female
AMC bed no 1
Unit 1
Date of admission:13/2/23
Fever spike present (99.8 F)
10 episodes of loose stools
No episode of vomiting
Nausea present
Cough present
O
Patient is conscious,coherent and cooperative
Bp-140/90 mmhg
Pr-112bpm
RR-24cpm
Spo2-98%
I/O-3300/500
CVS-S1 S2 present no murmur
P/A-soft,non tender
RS - BAE present
B/L infrascapular crepts present
SIRS CRITERIA(3/4)
PR> 90
RR>20
Hypertermia present
Leukocytes-9000 cells/mm3
A
Acute gastroenteritis secondary to ? Augmentin usage.bronchiolitis?
K/c/o hypertension since 10 years
P
Iv fluids NS and RL @150 ml/hr
Inj.Pan 40 mg iv/od
Inj.neomol 1gm iv/sos (if temp >101 F)
Tab.PCM 650mg po/tid
Inj.Zofer 4mg iv/od
Tab.Telma-H 40/12.5mg po/od
Tab.sporolac ds po/tid
1 ors sacket in 1 litre of water.100ml after each episode
Cap.redotril 100mg po/od
Tab.Doxycycline 100mg po/bd
Bp pr rr temp monitoring 4th hourly
16/2/23
51 year old female
ICU Bed no.4
Unit 1
Date of admission:13/2/23
Fever spike present (100 F)
Nausea present
Stools passed
No episode of vomiting
O
Patient is conscious,coherent and cooperative
Bp-120/80
Pr-102bpm
RR-20cpm
Spo2-97%
CVS-S1 S2 present no murmur
P/A-soft,tenderness present in the right iliac region
RS - BAE present
Left side inspiratory crepts present
SIRS CRITERIA
PR> 90
RR<20
Hypertermia present
Leukocytes-10700 cells/mm3
A
Pyrexia secondary to ? Lower respiratory tract infection
K/c/o hypertension since 10 years
P
Iv fluids NS and RL @150 ml/hr
Inj.Pan 40 mg iv/od
Inj.neomol 1gm iv/sos (if temp >101 F)
Inj.agumentin 1.2gm iv/bd
Tab.PCM 650mg po/qid
Inj.Zofer 4mg iv/od
Tab.Telma-H 40/12.5mg po/od
Bp pr rr temp monitoring 4th hourly
Date:15/2/23
ICU Bed no.4
Unit 1
Date of admission:13/2/23
1 episode of Vomiting since morning
2 episodes of loose stools
Fever spike present (101 F)
O
Patient is conscious,coherent and cooperative
Bp-140/80
Pr-100bpm
RR-18cpm
Spo2-100%
Grbs-93mg/dl
CVS-S1 S2 present no murmur
P/A-soft,nontender
RS - BAE present
Left side inspiratory crepts present
SIRS CRITERIA
PR> 90
RR>20
Hypertermia present
Leukocytes-11000 cells/mm3
A
Pyrexia secondary to ? Lower respiratory tract infection
K/c/o hypertension since 10 years
P
Iv fluids NS and RL @150 ml/hr
Inj.Pan 40 mg iv/od
Inj.neomol 1gm iv/sos (if temp >101 F)
Inj.agumentin 1.2gm iv/bd
Tab.PCM 650mg po/qid
Inj.Zofer 4mg iv/od
Tab.Telma-H po/od
Bp pr rr temp monitoring 4th hourly
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