A 67year old patient with fever

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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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

P.Manogna, Roll no.120

 A 67 yr old male patient came to the causality with 

chief complaints 

- fever since 10 days 

-body pains and generalized weakness since 10 days 

- shortness of breath since 5 days 

- abdominal pain since 2 days 

History of presenting illness

Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature . Their is a H/o burning micturation, dry cough , generalized weakness and body pains .H/o of an episode of vomiting on 4th day of illness had food particles as content which was no bilious and non projectile.

H/o breathlessness in exertion since 5 days 

H/o epigastric pain which is of squeezing type 

H/o abdominal pain since 2 days

PAST HISTORY :

-In 2007; he underwent Surgery for Aortic dissection.

 -And after 10 months Underwent ESWL for kidney stones in Right Kidney.

-H/O Hypertension since 15 years.

-No H/O Diabetes;Asthma;Tuberculosis;Epilepsy.

PERSONAL HISTORY :

-He wakes up at 5:00 am and 

-Does his work as milk vendor ; 

-Eat's meal for 3 times a day and had good appetite and 

-Has adequate sleep and 

-Bowel - regular 

-H/O burning micturition since 10 days. 

-No addictions.

FAMILY HISTORY:

No similar complaints in any one of his family members. 

GENERAL EXAMINATION:

Patient is Conscious; Coherent and Cooperative and Well oriented to time;place and person. 

Icterus is present

No Signs of 

Pallor,clubbing,kolinychia,

generalised lymphadenopathy, bilateral pedal edema absent

VITALS :

Pulse Rate          -   102 bpm

Blood pressure   -  90/60 mm of Hg

Respiratory Rate - 26cpm

SpO2                     - 97%

GRBS                     - 150mg/dl

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

INSPECTION:

Shape of abdomen- distended 

Engorged veins       -Absent

PALPATION:

No rise of temperature 

 Epigastric tenderness 

No palpable mases

No hepatomegaly

No splenomegaly 

 

PERCUSSION:

normal liver span

ASCULTATION :

bowel sounds heard

Respiratory system;

-Shape of the chest normal, 

-Trachea appears to be in centre 

-6 to 8 inch longitudinal Scar is present over the sternum.

-Normal vesicular breath sounds heard 

Cardiovascular system;

- S1 S2 heard 

- No murmors

CNS EXAMINATION 

- pateint is conscious 

- speech normal 

INVESTIGATION

USG 

 

ECG 

 

PROVISIONAL DIAGNOSIS

Leptospirosis ?

TREATMENT

- Iv 20NS 20 RL @75ml /hr 

- Inj pan 

- Inj ceftriaxone 

- Inj neomol 

- Tab dolo