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16 /M with pyrexia under evaluation

  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". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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.

Name :- Kattekola Sathwik

Roll no 75

Case Report 

Patient came to casuality with c/o fever sonce 2 days and cough since 2 days 

History of Presenting Illness:-

Patient was apparently normal 2 days ago then he had fever which was insidious in onset gradual in progression ,high grade, intermittent,associated with chills and Rigors and relived on medication 

C/o Cough with expectoration since 2 days whitish mucoid sputum ,non blood tinged,no foul smelling

No h/o Nausea, vomiting, pain abdomen,  SOB,Loose stools,Burning micturition

C/o Generalised weakness since 2 days 

PAST HISTORY 

Not a K/C/O DM , HTN, ASTHMA, TB, EPILEPSY, CVA, CAD, THYROID DISORDERS 

Personal History 

He is a student 

Appetite :- normal

Diet :- Mixed

Bowel and Bladder :- Regular

Sleep :- Adequate

Addictions :- nil

Family History 

No similar complaints in Family 

General Physical Examination 

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 

Temperature : 101.5 F

PR:- 110 bpm

RR:- 20cpm

Spo2 :- 100 % @RA

GRBS :- 88mg%

CVS :- s1s2 + no murmurs

RS:- BAE+ NVBS HEARD 

PA:- SOFT NT 

CNS :- NFND 





Investigations 

Chest X Ray


ECG



HEMOGRAM 

LFT
RFT


MP STRIP TEST
RBS
DENGUE NS1


Treatment (8/3/23)
1. Inj. NEOMOL 1G IV STAT
2.IV FLUIDS AT 75 ML PER HOUR
3.INJ.NEOMOL IG IV SOS (IF TEMP > 101F)
4.T.PCM 650 MG IV TID 
5.SYP. ASCORYL LS 1 TSP TID
6.INJ.OPTINEURON 1AMP IN 100 ML NS IV OD



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