MEDICINE LOG

-103 Pavan



This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 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, come up with a diagnosis and treatment plan.



45 year old Female, farmer by occupation came to medicine OPD with chief complaints of

  • Fever since 4 days
  • Loose stools 1 day back

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic  then she developed  low grade fever 4 days back which was insidious in onset and intermittent in nature associated with chills and rigor, no measures were taken. 

Loose stools 1 day back ,4 episodes liquid in consistency ;not associated with blood

No history of burning micturition

No history of pain abdomen

No history of intake of outside food.


DAILY ROUTINE:-

Patient wakes up at 7 AM and does her household chores and have breakfast around 9 AM and goes to work for 3 hrs and comes back between 12-1 PM and have lunch at 2PM, takes rest for the day. Patient have dinner at around 8PM and goes to sleep at 9PM.She takes rice with curry or dal for three times.

PAST HISTORY:-

Not a known case of hypertension,DM,Asthma,Epilepsy,Thyroid disorder,tuberculosis.

Hysterectomy done 15 years back

History of similar complaints 1 year back.she took treatment at our hospital(medication-unknown)

History of left renal calculus 9 months back.


FAMILY HISTORY:-

Not relevant     

PERSONAL HISTORY:-

Appetite :- Normal

Diet          :- Mixed 

Sleep        :-Inadequate

Bowel       :- Increased movements 

Addictions :- Occasional toddy drinker

GENERAL EXAMINATION:-

Patient is consious,coherent, and cooperative well oriented to time place and person moderately built and nourished 

Pallor - Absent

Icterus - Absent

Cyanosis -  Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal edema - Absent



VITALS:-

Tempurature - Afebrile

Pulse- 68bpm

Blood pressure - 110/80 mmhg

Respiratory rate - 21 cpm

SYSTEMIC EXAMINATION:-

CVS- 

Inspection:-

JVP not seen

Auscultation

S1 S2 heard

RESPIRATORY SYSTEM

chest is bilaterally symmetrical

bilateral airway entry present

trachea - Midline 

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

shape- scaphoid

no tenderness

liver not palpable

spleen not palpable

CNS EXAMINATION

speech normal

no focal neurological deficits seen



Provisional diagnosis:-

Acute gastroenteritis 


INVESTIGATIONS

On 14/06/2023

Complete blood picture

hemoglobin - 12.0 gm/dl

total count - 5,900cells/cumm

neutrophils - 62%

lymphocytes - 31%

pcv - 34.6%

MCHC 34.7

MCV - 87.2

MCH - 30.2

Platelet count -2.66

blood group A+

interpretation- Normocytic normochromic blood picture


Random blood sugar - 99 mg/dl


Renal functional test

urea            35 mg/dl

creatinine 0.8mg/dl

uric acid    2.8 mg/dl

sodium    136mEq/L

Potassium -3.3 meq/l

chloride -106 mg/dl

COMPLETE URINE EXAMINATION:-

Liver function test

Alkaline phosphate    199 mg/dl

total protein               7.0 gm/dl

albumin                       3.10gm/dl


ECG:-

TREATMENT
IV Normal saline
Tab.Dolo 650 mg PO/BD






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