GM CASE WITH FEVER AND CHILLS

 A 65 yr old male with fever and chills

June 08,2023

This is an 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. is an 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.


A 65 years old male patient daily wage by occupation came to casuality with chief complaints of high grade fever ,chills and rigors, generalised weakness since 3 days 


History of presenting illness::

Patient was apparently asymptomatic 2 yr back and then he developed high grade fever, intermittent, relieved on medication 

patient had generalised weakness since 2 days

Patient is unable to daily activities since 1day

C/o giddiness  since 1 day,

H/o fall (syncope)

H/o loss of consciousness ,SOB,chest pain, Palpations 


Past History:

Patient is a known case of diabetes mellitus since 2 years

H/o left lower limb filariasis since 20 years


Personal history:

Apettite-normal

Diet- mixed

Bladder- normal 

Bowel -regular

ADDICTIONS:
Alchol- regular, since 5 years

Family history: 

No significant

General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

Pallor absent 

No Lymphadenopathy-

No Peadal.edema

No icterus cyanosis, clubbing.

VITALS :

Temp : 102.6 f

Pulse rate-110 bpm

Blood pressure :160/80mmhg

Respiratory rate :25 cpm

Spo2 : 98%


SYSTEMIC EXAMINATION:


CVS :

Palpation:

No Cardiac murmurs 

Auscultation: S1,S2 are heard

Respiratory system:

Inspection: chest shape normal, 

Dyspnea: no

Palpation: trachea -central

Vesicular breath sounds 

 

Abdominal examination: 

Shape : scaphoid

Tenderness -no 

Free fluid -no 

Liver,spleen -not palpable 


CNS: No focal neurological deficit 


MANAGEMENT :


INVESTIGATIONS : Hemogram ,LFt ,serum  electrolites,cbp,Grbs,Usg,ecg

Hemogram:






Comments

Post a Comment

Popular posts from this blog

82 YR OLD FEMALE WITH BILATERAL LOWER LIMB WEAKNESS AND PEDAL OEDEMA

Image
82 year old female with B/l lower limb weakness and pedal edema. on June 21, 2023 This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.  DEIDENTIFICATION -  The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever. CASE DISCUSSION - 82 year old female patient came with C/O weakness of lower limb, Neck and shoulder pain since along with pedal oedema and fever since 10 days. HOPI - Patient was apparently asymptomatic 10 days back then she developed weakness of the lower limbs, sudden in onset, non-progressive.  Also, C/O fever since 10 days low-grade not associated with chills and rigours, continuous, relieved on medication. C/O pedal oedema since 10 days, pitting type, from ankle to knee. No C/o chest pain, palpitations, cough, cold, LOC PAST HISTORY- K/c/o of HTN since 10 years(On medication- Telma 40mg) Not a k/c/o DM,
Read more

117-gopi

Image
A 30 year old female presented with fever and swelling of both the Limbs             September06,2022                                                                                                  Hi , I am T Gopi(roll no 117) of 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.                   CASE SHEET.           CHIEF COMPLIANTS: A 30 year old female patient who was a farmer by occupation and resident of Miryalaguda came to OP  Fever : 7 days  Lower right abdominal pain : 7 days  Lower back pain : 7 days  Dry cough and sore throat : 2 days HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 6 months back. She developed joint pain following fever, for which she was treated in private hospital at Miryalaguda and now she came with compliants of fever which aggravated at evenings and also intermittent associated with chills and rigor. She com
Read more