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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
60yr old female came with complaints of fever since 10 days
-productive cough since 10 days
-vomitings since 10days
HOPI -
Patient was aparently asymptomatic 10 days back.She then developed fever low grade,intermittent ,not associated with chills and rigors ,relieved on medications
C/o cough with expectoration since 10 days ,whitish mucoid sputum not blood tinged
C/o nausea and vomitings since 10days 2- 3 episodes per day which is watery ,non projectile ,non blood tinged with food particles as contents
C/o constipation and decreased appetite since 10 days
C/o pain in the back while coughing
No H/O Burning micturition,loose stools,pain abdomen
No h/o pedal edema,chest pain, facial puffiness,decreased urine output,SOB, palpitations
Past History-
No similar complaints in the past
N/K/C/O - DM,HTN,TB, Asthma, Epilepsy, CVA, CAD, Thyroid disorders.
Personal History-
Diet- Mixed
Appetite- Decreased since 10 days
Bowel & Bladder Movements-H/O Constipation since 10 days
Sleep - Adequate
Addictions - None
Family history: insignificant
GENERAL EXAMINATION-
Patient is Conscious, Coherent and Co operative .
Pallor present
No signs of ,Icterus Clubbing, Cyanosis, Lymphadenopathy
TEMP: 100.6F
BP: 100/70mmHg
PR: 112 bpm
RR- 16cpm
Systemic examination:
CVS:
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS
Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
PER ABDOMEN
On inspection:
All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars, engorged veins ,sinuses.
On palpation::
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity
On percussion::
Tympanic note - heard
On auscaltation::
Bowel sounds heard
Provisional Diagnosis-
PYREXIA UNDER EVALUATION
Investigations:
Treatment-
1.Inj- NEOMOL 1gm SOS
2.Inj.OPTINEURON 1AMP IN 100 ML NS IV/OD
3.Inj.Zofer 4mg IV/BD
4.Tab.PCM 650mg PO/BD
5. Tab.levocetrizine PO/BD
6.IV FLUIDS NS,RL @75ml/hr
7. SYP.ASCORYL -LS 5ML PO/TID
8.SYP.CREMAFFIN PLUS 15ML PO/BD
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